A note from Pocket Doc: Why I do what I
do and why did we start our business?
"Pass It On"
"Why do you do it, Doc?"
That's a question I hear a lot. The short answer is,
"Man, I love it. I just absolutely love it."
The long answer?
Well, I'm glad you asked.
I have been taking care of people for the majority of my
life. Twenty-one of 41 years on this Earth, I've been
I've also been teaching folks how to help themselves and
I've been a combat medic, flight medic, paramedic and
critical care and ER RN.
Taking care of folks is just in my blood. I don't
remember much from when I was a little goober, but I
have a memory from when I was probably about 3 years old
and my daddy was lying on the couch in front of the
fireplace with his head in my mama's lap, sick with a
bad cold or something and I took out my little black
plastic "doctor's bag" with my stethoscope, reflex
hammer, BP cuff and a syringe. I was telling him I was
going to "fix him up". As I gave him his 'exam', I have
one of the best memories ever of my dad in that moment.
He looked up at my mother and said, "Jeanette, he's
going to be a healer." I remember it as clearly as
though it was yesterday and I don't think I'll ever
When I was in elementary school, if one of my friends
tripped on the playground and skinned their knee, I ran
up to them to help them up and check on their knee and
get the bleeding stopped. I was always walking around
with a little tin of Band-Aids. (How many of y'all
Years went by and I learned my true passion for medicine
and teaching in the United States Air Force. I
volunteered to teach every Self-Aid and Buddy Care
course I could as well as being the camp medic for the
Boy Scouts during their Summer Camp where I taught them
their First Aid Merit Badge course. I was hooked! I
loved this stuff and I took every course I could and
bugged the heck out of all the doctors and PA's with my
Fast forward a few years to 2006. I was seeing a lot of
news coverage of law enforcement shootings, active
shooters, car accidents, industrial accidents, hunting,
hiking and camping accidents where just a little
training and knowledge could've gone a long way. I felt
that there really wasn't anything out there for the
"Average Joe" other than some basic first aid and/or
First Responder training as many folks didn't want to or
couldn't afford the time or money to do the EMT route.
There was a gap between Self-Aid/Buddy Care and Combat
Lifesaver classes in the military to the civilian EMT
courses and I was determined to fill that gap.
I started with a basic outline and then fleshed it out
into a viable curriculum and then went a step further
and had it copyrighted so that it was really mine. Then
I started teaching it to folks. Anyone who'd listen! I
was actually developing a philosophy of simple,
effective training and using simple, effective items. I
was able to combine my love for both medicine and
firearms and teach for a couple of pretty reputable
companies in order to get this information out to as
many folks as possible.
Then I had an epiphany. I had carried so many different
kits in the military and found them all to be too
cumbersome, overstuffed and too hard to use under
stress. I thought I should develop a kit which reflected
my training philosophy of simplicity under stress. So, I
worked with folks on several prototypes and over the
period of over 3 years of prototyping and field-testing
these kits in live-tissue labs and with 'boots on the
ground', I pared and tailored the kit down to what it is
today and the Direct Action Response Kit was born.
My wife and I formed Dark Angel Medical, LLC during this
time with the sole purpose of marketing our kit but my
passion still lay in telling people how to use it and
other kits, and more importantly, "WHY?"
I absolutely love what I do. Every single aspect of it.
I am totally passionate about the training and the
products and I have thrown myself completely into this
endeavor. I am not feeling compelled to make huge
financial gains, I'm feeling compelled to spread the
word that helping others really isn't that hard if you
know what to look for and what to do.
My reward is far more than any monetary gain. My reward
is seeing the 'light' click on in the students' eyes
when they "get it". My reward is hearing how they've
utilized the training to help themselves or someone
else. My reward is hearing about how they've passed on
the knowledge which they gained in a class. My reward is
knowing that my kit is out at the tip of the spear, on a
patrol belt, in a purse... standing ready to save a
life. My reward is being fortunate enough to have the
opportunity to pass on what I've learned over the past
21 years. My reward is the legacy of knowledge and
knowing that I have truly helped others.
If I lived to be 100 years old, was the most educated,
experienced medic in the world and I chose to never pass
on what I've learned, not a single soul would benefit
from it. However, if I died tomorrow, I know that I have
done something good just for the sake of doing good. So
pass on that knowledge. Share it. Empower others. My
reward is knowing that I have helped and that my
training philosophy has made a difference in the lives
of others because I have passed it on.
And that, my friends, is the long answer to why I do it.
Please have patience with me as I play with the design to
facilitate its ease of understanding and use.
NOTE: THIS IS WEB PAGE IS A WORK-IN-PROGRESS AND IS NOT YET
COMPLETE. HOWEVER THE TEXT IS THE ORIGINAL AND COMPLETE SO ONE
MAY STILL GET THE PROPER MEDICAL TECHNIQUES AND INFORMATION FROM WHAT
I HAVE SO FAR.
TABLE OF CONTENTS
Techniques, Tips and Procedures
(TTP with Wings)
See if you know what to do if you saw this range accident CLICK
Remember the same principles apply to our loved ones too!
We are a veteran-owned business
with a combined total of over 40 years of medical training and
work in both the military
fields, Pre-hospital care, flight medicine and
intra-hospital work with
concentration in emergency and critical care medicine as well as
law enforcement and competitive shooting.
We are very proud to offer the D.A.R.K.
(Direct Action Response Kit) which has carefully selected,
combat-proven components with a low learning curve enabling almost
anyone to be able to deploy and utilize the kit.
We want to give every person who deploys these kits the ability to
survive a life-threatening situation without worrying about "what
goes where?" and "what does what?". In a time-is-life event you
need simplicity. That’s
we’re all about.
NOTES TO SELF:
You and a
friend are mountain biking and your friend hits some loose
stone on the side of the trail and goes down a small,
sloping drop off about 8 feet and into an old dead tree
lying on it's side. You
hear him yelling in pain,
your D.A.R.K. and as you
scramble down the slope you notice he's impaled his left
lower leg on a sharp branch coming from the trunk of the
tree. The branch is roughly 18" long and the wound has dark
red blood coming out of it.
do you do?
HINTS AND INFORMATION TO HELP FOLLOWS IN THE TAC MED TIP OF THE WEEK #25
everyone, after reading through the answers on the latest POP QUIZ (the
bicyclist with the impaled leg), we thought we'd throw out some info
which we think would be beneficial. Take a peek, give it a read and if
you like it, share it with your friends and loved ones. Knowledge is
power. Stay safe. -Pocket Doc
Tac Med Tip of the Week # 25-- 28 September 2012
“Blood Goes ‘Round and ‘Round”
(Bicyclist injury scenario)
We used to have a saying about bleeding and breathing in my military
classes, “Blood goes ‘round and ‘round, air goes in and out
and any deviation thereof is bad.” Today, we’re using,
along with that one, “Stop the bleeding, start the
To do this, we need to know a little bit about basic human anatomy and
physiology. The more we understand the basic functions of our body, the
more we’re able to understand and rationalize what needs to be done in
an emergent situation.
Take bleeding for instance. There are a lot of misperceptions about
venous and arterial bleeding. What is bright red and what is not? What
is steady and what pulses? To know how to better take care of a bleed,
we need to understand how blood circulation works.
Our body is a hydraulic machine. The heart is the pump, the vessels are
the hoses/tubing and the blood is our hydraulic fluid. Pump, Tubing,
Fluid. Any interruption of one of these components could make the
machine break down if it’s left unchecked. It’s up to us to be the
mechanic and fix it.
Basically, as we inhale, we take in oxygen, it’s absorbed at the
microscopic capillary level in our lungs and attaches to red blood
cells, as we exhale, the waste, carbon dioxide, is expelled from our
body. Our body has a very fragile pH system and must
remain at 7.35-7.45 to maintain balance. Too much in
either direction can have dire consequences.
for more material on the human circulatory system
(click for full-sized images)
The Pump: The oxygen binds to a substance in our
red blood cells called hemoglobin. This blood is pumped back to the
heart by the pulmonary veins (the only veins in the body that pumps
oxygenated blood), it goes into the left atrium (top left chamber of the
heart) through the mitral valve and squeezed up through the muscular
left ventricle (bottom left chamber of the heart) through the aortic
valve into the central circulation and out to all of the tissue in the
body by way of arteries, arterioles and capillaries perfusing our organs
and tissue with life-sustaining oxygen. As this is happening the
unoxygenated blood is traveling up through the venules and veins, by
vacuum and a series of valves in the veins to prevent backflow of the
blood, into the central circulation to the superior and inferior vena
cava and then enters the upper right chamber of the heart (the right
atrium). It flows from there through the tricuspid valve into the right
ventricle (the lower right chamber) up through the pulmonary valve and
through the pulmonary artery (the only artery which carries deoxygenated
blood) back into the lungs to exchange waste for oxygen.
The Tubing: Vessels can be broken down into
arteries, arterioles, capillaries, venules and veins. Arteries have 3
layers and veins have two. If this complex network of vessels were laid
end-to-end they would measure close to 60,000 miles! Think of arteries
as a high pressure fire hose and veins as a low pressure garden hose
without a spray nozzle on the end. Arteries are thick and muscular as
they have to support the high pressures of the blood being ejected from
the left ventricle into the aorta with great force. Veins typically have
a lower pressure as the blood in them than arteries do and have a series
of valves which prevents backflow of blood which could cause serious
These vessels range in size from the size of a small hose to microscopic
in nature. If an artery is dissected, the blood will spray from it much
like water from the nozzle of a fire hose. It will be bright red due to
it’s high oxygen content and will ‘spurt’ in a pulsatile manner due to
the contraction of the heart.
If a vein is dissected, blood will flow in steady fashion and be dark
red in color, due to the waste products, low oxygen content and low
Typically, an injury to an artery is more worrisome than a venous injury
due to the high pressure and high volume of loss in short period of
time. However, dissecting a large vein like the brachial, basilic,
femoral or subclavian can have devastating effects as well as they can
lose a good bit of blood very quickly.
The Fluid: The goal is to keep as much blood in the
body as possible.
Why? Blood has our clotting factors (fibrin, thrombin, platelets) which
help stop the bleeding naturally and it has our oxygen-carrying
capability (hemoglobin) which helps perfuse all of our organs with
oxygen. The more blood you lose, the less you’re able to clot, the more
you bleed, the less oxygen you get to all the tissues, the more waste
products (acid from excess carbon dioxide) build up, the more likely you
are to go into shock, the more your body can’t warm itself, the colder
you get, the more it affects clotting, the more you bleed, etc., etc.
This vicious cycle is known as the “Triad of Death”. Pretty fascinating
stuff. That’s our circulatory system in a nutshell.
Our bodies have a wonderful way of attempting to compensate and maintain
that fine balance but can only take so much of an insult before
decompensation and death occur. It’s up to us to understand not only
what to do, but why we’re doing it, the rationale behind it and what to
look for. The more we understand how our bodies work, the more effective
“mechanic” we can be when we break down or get into a wreck.
remember, “Stop the Bleeding, Start the Breathing.”
HINTS: Okay guys, here's the deal. There are lots
of large vessels in the lower leg.
don't have to dissect an artery to bleed out.
pressure may or may not work in this situation. Plus putting a ton
of pressure on that area can cause more damage and will increase
you choose to use direct pressure first and it fails, you'd best
have that TQ handy and place the TQ HIGH on the leg. Placement of
the TQ is critical to it's success. Occluding one
artery which lives next to one long bone in the upper leg is
much easier than trying to occlude several branches between two
bones in the lower leg.
times are also increasing to <4 hrs.
2008-2009 study in Iraq cited several hundred TQ placements that
didn't result in a loss of limb. The limb may have been lost as
a result of the injury which prompted the TQ placement but
by placing a TQ doesn't mean that what's below it will be
unsalvageable. That's what I learned when I was taking
TCCC and learning from some excellent SF medics and that's
main goal is stopping the bleeding by any means necessary as
quickly as possible. Primum Non Nocere -- First Do No Harm
THE CORRECT RESPONSE IN A NUTSHELL:
repsonsiveness as you approach him, determine if the bleed is
life-threatening, if so, TQ high on the thigh,
A, B, C's--if not life-theatening, direct pressure,
a quick neuro assessment,
and check for any other injuries and stabilize the object and
Until next time, stay safe.
Simplicity Under Stress
Training is essential to life.-Pocket Doc
Tac Med Tip of The Week #21 21 June 2012-06-22
We hold our lives in our hands every day. From the moment we wake up every
morning until the moment we go to sleep at night, our lives are fraught with
danger and risk.
What do we do to avoid and prepare for risk? We
put lids on our coffee cups, put on our seatbelts, buy automobiles with
airbags and collision avoidance systems, buy
health insurance, get a CCW license and a pistol….well, you get the point.
We are constantly attempting to avoid becoming injured or worse,
involuntarily ceasing O2/CO2 exchange.
While we are practicing this risk aversion, where are we making the time
to learn how to help ourselves and someone else in the event of a
potentially life-threatening injury or other event? Is this something we
prioritize low on the list of important things to do? Is it something we
overlook and just simply don’t think about? Do we expect someone else to
take care of us should some injury befall us?
We like to think of ourselves as responsible people by doing all of the
it also a responsibility to take personal accountability for our own
well-being and prepare for an unexpected medical emergency?
We prepare for every other scenario except this one critical, potentially
life-altering one. The skills needed to render aid are really not all that
complicated; the training not all that difficult. Yet it is a commonly
misplaced and often maligned skill set. Not only does it show that we are
responsible, it also proves that we are an asset to society rather than a
liability. It shows that we are prepared and that we are willing to take
charge and render aid, if needed. It shows that we want to be more
“Is the training “cool”? Because every medical class I’ve ever been to
wasn’t cool.” <- (Kat's note: firs-aid and tacmed training
for me is as cool as any tactical firearms course!)
Well, we’ll answer that question with a question? How “cool” would it be
to watch a friend, team mate or loved one die from an injury that could
have been easily treated provided you had taken the proper training? How
“cool” would it be to know you’re injured badly and have no idea how to
recognize or treat the injury? Pretty easy to answer those questions isn’t
it? But, yes, it actually is pretty cool. It’s very empowering to know
that you have the knowledge, the ability and the wherewithal to render aid
and make a difference in someone’s life.
We must realize that we are obligated to ourselves, our friends and loved
ones to better ourselves in every way possible and that includes receiving
some sort of emergency medical training. You don’t have to be an 18 Delta,
a Corpsman, a Paramedic, Firefighter, RN, MD or any other type of medical
personnel to save a life. The training doesn’t have to be long and
arduous. The training should be simplistic in scope and in practicality
due to the fact that if and when those skills need to be recalled, you’ll
be under a great deal of stress and the more difficult things are to
learn, the harder they’ll be to recall under stress. Remember, we
can only do 1-2 things very well under stress whereas we can do
7-8 things very well without stress.
All it takes is the willingness to take a class and an open mind to take
in the material and apply it to your everyday life.
The life you
hold in your hands every, single day.
Until next time, stay safe.
Simplicity Under Stress
SCENARIO: MULTIPLE INJURED ACCIDENT VICTIMS AND APPLYING THE
RULES OF TRIAGE*
|trēˈä zh; ˈtrēˌä zh |
1 the action of sorting according to quality.
2 (in medical use) the
assignment of degrees of urgency to wounds or illnesses to decide
the order of treatment of a large number of patients or
verb [ trans. ] assign degrees of urgency to
(wounded or ill patients).
Life can change in the blink of an eye. Will you know what to do?
Tac Med Tip of the Week #19
23 May 2012
It’s a beautiful day
outside as you drive down a rural road with your windows down, completing
some errands and enjoying the scenery. You’re a couple of car lengths
behind a blue van and you can see the silhouettes of at least three pairs
of little hands and 3 little heads and you say to yourself, “Man, they
have their hands full!” as you head into a curve.
Suddenly, a car
‘cheating the curve’ comes around the bend, pulls into the van and the van
lurches off the side of the road and rolls end-over-end several times in a
deafening crash of breaking glass and twisting metal as the car flies into
a stand of trees.
I expect to see motorcyclists cheating curves while mountain.
It's sad, but their organs provide a life-saving service
Sadly there are
"Expectant" or "Black" patients
This was the result of a mortar attack
If you can,
please see HBO's Baghdad Hospital.
Listen carefully during the hospital meeting, you'll hear how many
units of blood were needed on the average there and you will get a
real sense of respect for both the staff and chaplains.
You immediately get close to the edge of the road, turn your emergency
flashers on, call 9-1-1 and give them your location and let them know what
happened and that you’re going to try to help. You grab your first-aid bag
with your D.A.R.K. and head down the steep embankment.
The first thing you notice is that the van is right-side up but severely
damaged. You hear high-pitched cries and voices calling for “mama”. As a
parent, this is a nightmarish scene, but you press forward.
The car ‘cheating the curve’ has hit the trees on the edge of the road and
you get to it first and notice an adult-sized figure resting on the hood of
the car face down. As you get closer, you notice a large pool of blood on
the hood and that half of the driver’s face is gone. The
are locked open and there are no signs of life. You move on to the
sounds of voices.
There are two small children, a boy and girl, 8-10 years old, walking
in a daze with small cuts to their arms, crying. You ask them what
happened and they tell you that they got out of their seat belts and got out
of the van.
As you’re asking them this you notice an adult and a child lying close
together. The child
appears to be about 4 years old and has frothy, pink bubbles coming from
an area on her left upper chest and is whimpering and crying for her
The adult is a female, with
an open fracture of the left femur with bright-red pulsatile bleeding
calling for help for her baby. You
ask her what her name is, what day it is, what happened and she tells you
You deploy your TQ,
wrap it high
around the upper thigh, near the inguinal crease and tighten it down until
no bleeding is present. You then grab
your HALO seals and expose the little girl’s injury and wipe away any
blood, affix a seal to the front and check the back for any exit wound.
Finding none, you utilize the 4”
Emergency Bandage and secure it to her chest, applying
pressure over the wound and place her on her affected side in the recovery
While you’re doing this you
ask her what her name is and she says, “Daisy…like the flower.” You
grab a couple of space blankets out
of your bag and wrap both the small child and her mother in them.
You check on the boy and girl, grab your gauze
and shears and begin to dress their small, superficial cuts and
thankfully hear the wail of approaching sirens.
completed triage and treatment of multiple motor-vehicle accident victims
to the best of your ability.
means “to sort” and by doing that, we are simply doing the most
good for those whom we can actually help. This means in a mass casualty
situation such as this, we have to adhere to some basic triage principals
and categorize them with colors according to their injuries.
Our Minimally Injured/walking
wounded are our “Green”
patients and can either treat
themselves or be left to attend to until later.
Our Delayed patients are
those with sprains, fractures that can
wait to be stabilized after more urgent patients are attended
to and are “Yellow”.
The most Immediate patients,“Red”,
are those who are in danger of
bleeding out or have airway or breathing injuries and can be corrected
(ILS-Immediate Lifesaving Intervention)
You’ll notice we had two of these. The mom was in greatest danger due to
life-threatening hemorrhage while the little girl’s open pneumothorax
could wait, even though still a Red. You may have to triage within
categories just like this.
Once stabilized, an immediate could be downgraded just as a lower category
can be upgraded if they degrade. Just remember to constantly reassess the
victims frequently, gauging mental status changes or other signs and
symptoms, checking TQ’s and bandages, respiratory effort, etc.
The final category is Expectant
or “Black” in which we
can’t do anything at the POI (Point of Injury) to assist them.
These are patients who have no obvious signs of life or who have sustained
such grievous injuries (exposed brain tissue, near decapitation) that our
capabilities would be ineffectual and would be time spent on them that we
could be spending assisting others who both need and would benefit from
our aid.Move on to those you can
about selecting who lives and who diesbut
is about helping those whom you know you can help in the
quickest, most effective manner possible and our skills in triage
may be called upon in something as ‘simple’ as a motor vehicle accident.
If there’s more than one patient, triage principles apply.
Triage: Sort them out-Do the greatest good for those
you can help.
Field Triage Flow
Chart, CDC 2011
Until next time, stay safe.
SCENARIO: A VIOLENT HOME INTRUDER AT NIGHT
It's been a while, so here is a little something we thought up this morning.
Always be a student!
Tac Med Tip of the Week #18—17 May 2012
It’s 0300 and you and your family are sleeping well. You’ve got a long day
ahead of you and need all the rest you can get.
All of that changes in an instant as you hear glass shattering and the
cracking sound of the wood on your door frame of the front door giving way
as it’s being kicked in. It’s an all-out auditory assault as the security
system siren blares next to your room, your youngest daughter screaming and
crying as she runs into your room in terror. You reach over and unlock your
pistol safe and grab your pistol, do a quick press check and grab an extra
mag as your spouse grabs their pistol from their side of the bed. They take
the kids, who are all in the room by this time, and the cell phone and calls
9-1-1 as the kids go into the closet and lock the door.
Your spouse maintains rear security in the bedroom as, with your heart in
your throat and your legs shaking, you begin to pie out of your bedroom and
look down the stairwell leading to the first floor.
As your turn the corner, you engage your weaponlight down the stairs and you
notice a black clad figure at the bottom of the stairs putting a foot on the
first stair leading up to the bedrooms. You
quickly identify a black pistol in the right hand and a flashlight in the
left hand of the intruder. Your heart is pounding in your chest,
the grip of the pistol suddenly feels slick and your mouth is as dry as the
desert as your body’s ‘fight or flight’ response kicks into overdrive.
Somehow the words come out of your mouth, “Stop!
Drop the gun! Don’t move! Don’t make me shoot you!” As you yell,
the intruder bounds up the stairs with the gun pointing up at you.
You hear several muted ‘pops’ and notice strobe-like flashes as the intruder
crumples to the floor at your feet. Your spouse is moving to you and yells
to you if you’re okay. You yell, “Good to go.”
Your spouse gives the password to the kids who unlock the door but stay
where they are. You kick the gun away from the invader’s hand and you are
surprised as you notice smoke coming from the muzzle. At the same time you
feel a sharp stabbing pain in your upper left chest. You transfer your
weapon to your support hand and raise your right hand to your chest and it
comes away covered in blood as
you notice a distinct sucking sound.
You yell at your spouse to grab the D.A.R.K. that’s kept in the bedroom as
you remember your training and place pressure with your weapon hand over the
entry and have your spouse check for an exit wound.
There is none. As you place the HALO Seal over your wound, you notice the
invader move and a large pool of blood spreading out from under them.
Your spouse ‘gloves up’ and rolls them onto their back and notices a bright
red blood coming from the lower thigh above the knee in a pulsating manner.
They quickly grab a CAT and secure it near the top of the thigh and turn the
windlass until the bleeding stops.
They then are checking the airway and breathing and looking for other
They notice three wounds, 2 to the upper right chest and one to the abdomen.
The remaining HALO seal can cover the 2 to the chest but there is an exit
wound. Your spouse grabs the ‘backer’ that the HALO seal came on, places it
over the wound, unwraps the compressed gauze and binds it around the torso
of the intruder and ties it to form a makeshift occlusive dressing. They
then grab the Israeli Bandage and the QuikClot Combat Gauze LE and dress the
abdominal wound, placing the victim on their right side in the recovery
Around this time, LE, Fire and EMS all roll up to your house and your very
long day has just begun.
What did we discuss in this scenario?
Body alarm response,
Triage of multiple patients and
This family had a plan.
Unfortunately, we live in a day and age where we don’t just need to do fire
drills in our homes. We also need to plan
for home invasion. To that end, we also must realize that if we use
deadly force and the intruder is not killed outright that we may be legally
responsible to provide lifesaving medical care for them or be criminally or
civilly liable for negligence.
Get the proper training to utilize your firearm.
Make a plan with your family.
Get the proper training to utilize a personal trauma kit.
Know your states’ laws concerning your responsibilities and
liabilities if deadly force is used.
Make every day a training day.
Until next time, stay safe.
Simplicity Under Stress
Visualization is one of
the most powerful methods of training for an event which is
difficult to simulate.
Without becoming paranoid fearful, a discussion of an
emergency plan for your family is as important as having one for
an out of control house fire whether your family is accessible
The important safety and accuracy rules will be taught in any
competant course as well as the basic laws of self defense.
Currently, it is becoming almost mandatory to either have a
light attached to your firearm or be proficient at the methods
of using one in your support hand.
You need to be able to
see and identify an intruder and be aware of what or who is
downrange of your target. Tragic accidents have
happened when a frightened untrained person shoots at a shadow.
Military personnel in Close Quarters Combat will do a flash
overall identification of the potential target to prevent
shooting at a member of their own team (in this case your
The next and extremely
important place to watch is the person's hands.
You have to see the hands to be sure of the threat. This
may not be necessary depending on the nature of your state's
Castle Doctrine. But it will help your own feelings
after as well as the fact that a prosecuting attorney will
certainly ask how you knew that it was a lethal threat or just
a drunk person accidentaly coming into your house.
You must be prepared to fire several times -
accurately. No caliber is always immediately nor 100%
effective - this includes 12Ga 00Buck and 1 oz slugs. An
attacker shot in the heart may have 10 seconds of life before
succumbing to blood loss. If you had a weapon and you
knew you were going to die in ten seconds, how much damage
would you be willing to do?
A tactical first-aid
knowledge of how to use one and a cell
phone (experienced robbers/burglars will sometimes cut
power and phone lines before entering) in
the bedroom are extremely good to have.
Cover and clearing your house by "slicing the pie" is
something which can and needs to be learned from a good
instructor. You cannot help your loved ones if you are
In order to become proficient enough with a firearm to be able
to operate it even if you are paralyzed with fear takes
practice; enough practice that everything (especially safety) is
in muscle memory.
Over 20+ years of firearms instruction has taught me two
The average person who buys a handgun for self-defense
will shoot perhaps one box of twenty rounds and then keep it
(hopefully locked) in their nightstand or closet.
you are on a static range, you will be at best half as
accurate when you and your attacker is moving, even if you
In order to get good
enough, you must discover that shooting is a fun, exciting
(and yet relaxing) activity which can be a terrific bonding
event for a family.
If you can locate an attorney ahead of time who is experienced
and successful at defending gun owners you will save a lot of
stress when you have to deal with legal authorities.
Hey everyone, it's that time again, so get your learn on! We skipped last
week as we were out in the great state of Texas teaching a "Bullets and
Bandages" class. During class, a lot of questions were brought up about
field expediency and we thought a Tac Med Tip of the Week on that subject
was in order.
Not everyone will have a D.A.R.K.
on them if something happens (even though they should! ;-) )
And....sometimes things happen that are even beyond the scope of the
Those of us who work in an environment where we have a lot of commercial
items readily available, myself included, tend to get a little spoiled by
Now, imagine having to utilize what you have around you and
what's on hand to assist someone with a traumatic injury of some sort.
Let's talk about hemorrhage
control. What if you don't have a TQ handy. Can you make
one? Absolutely. As long as you have the right material available. Remember,
TQ's work not only from the
force of the compression but also from the surface area being
compressed. So, you'll
need a compression band at least 1" wide so that you don't cut into
the tissue and create more trauma. You'll
also need a windlass (the thing you turn to tighten the tourniquet)
and you'll need something to secure the
What to use for a TQ? Ideas.
What can you use? Look around you. Belts, bandanas, scarves, shemaghs,
backpack straps, sleeping back straps, rifle slings…etc. The list goes on
and on. You don’t
want to use anything like paracord, wire, bootlaces, rope or anything
small that can cut. What about a windlass?
How about a pistol mag, SureFire E2D or similar light, a stick,
etc. Think outside the box. Also, you
don’t want to make it too complicated as you have only a short
period of time to get this thing on and get the vessel occluded before the
victim loses too much blood and either goes into shock or, worse, dies.
Just like with a commercial TQ, and especially with a field expedient one, you
must constantly reassess for any bleeding and watch for signs and symptoms
Not a whole lot we can do here other than the Recovery
Position. Remember you don’t want to be placing anything in
anyone’s airway that wasn’t designed to go there unless you have the
training and it’s in your scope of practice. Remember
“Primum Non Nocere”…”First, Do No Harm.”
precautions? You can roll up cardboard and tape it to either side
of the head. Same with towels, blankets, shoes, boots, etc. The
is to keep the head in a neutral position and limit lateral movement.
No tape? Use a belt or other similar strap to secure the head and remember
to watch out for the airway so as not to occlude it.
So someone has a thorax injury and
you don’t have HALO Seals. Anything
which is airtight and extends at least a
couple of inches beyond the wound border and can be secured in place
with tape or other devices can be a very effective occlusive dressing.
Plastic bags, packing materials, duct tape, electrical tape or anything else
which can create an airtight seal can be utilized.
The same principals apply to these as they do to commercial dressings. Watch
for development of tension pneumothorax,
burp the wound if necessary and always, always,
always…check for an exit wound.
Direct pressure remains king in non-life threatening hemorrhages. Try to
find some sort of material which can cover your hands to prevent blood or
other body fluids from reaching your skin, grab some absorbent material
(t-shirt, towels, pants leg, etc), hold pressure and keep the bleed
controlled. If one dressing becomes saturated, place another over it and
continue to put the pressure on it. These materials can also be used as
expedient packing into a wound. Antibiotics will come at a definitive care
facility. You can use shirt sleeves, jacket sleeves, belts or other
compressive device to make a field-expedient pressure dressing as well.
Place a golf ball or smooth rock underneath a layer of material as you
compress it to focus pressure down into the wound. Constantly
monitor for any rebleed or signs and symptoms of shock.
Don’t have a SAM Splint handy? How about using lumber, sticks, rolled up
newspaper or magazines bound in duct tape, table legs, notebooks, etc. The
thing with splints is to remember to immobilize the joint above and below
the fracture, pad for comfort and don’t tie anything over the fracture
site. Check Circulation (cap refill), Motor Function (wiggle
fingers/toes) and Sensation (ask if they can feel tapping or pinching on an
area distal to the injury) before and after splint application, keep it
elevated and compressed and check for further underlying injuries.
Those are just a few of the biggies and there are many, many more
field-expedient items which could be utilized. Try to carry items that are
multi-purpose and you won’t be disappointed. The goal here is to stay calm,
think outside the box, utilize what’s in your environment and get your
Keep if safe. Keep it simple.
Until next week, stay safe.
SIMPLICITY UNDER STRESS.
Recognizing and Treating Fractures
Tac Med Tip of the Week #14---16 March 2012
This week, in honor of all the St. Patrick’s Day celebrations and inevitable
injuries resulting from overindulgence in green beer, Jameson Whiskey and
Guinness, we will discuss how to treat fractures.
Before you can properly evaluate and
treat injuries, you must be able to answer three questions:
1) What is it? 2) How do I recognize it? 3) How do I treat it?
First off…what is a fracture?
A fracture is the break in the continuity of a bone and can be simple
(closed) where the bone has broken but not come through the skin or it can
be compound (open) where the bone has broken and exited through the surface
of the skin and may or may not be protruding.
How do I recognize a fracture?
Well, if someone’s upper leg is bent at a 90 degree angle, that’s a pretty
good indicator of a fracture. However, not all fractures may be that obvious
and many are mistaken as sprains. A fracture may or may not have deformity.
This is the difference between a displaced (deformity) or a non-displaced
(no deformity) fx
(medical abbreviation for fracture).
The fractured area may have had a ‘pop’ or ‘crack’ sound followed by
If the bone ends rub together you may hear or feel a ‘crunching’ sound
(example: Lay a box of Frosted Flakes cereal on it’s side and press down on
it…did you get chills? Yeah, that’s crepitus)
There will be point tenderness, bruising and swelling associated with the
fracture too. Also, there may be a loss of function or decreased/impaired
ROM (Range of Motion), meaning that the affected area (especially in
extremities) may now be essentially useless.
There may also be circulatory compromise and nerve damage.
Bones are pretty hard in a healthy person and it takes a good bit of force
to break them. (Think of other MOI’s –Mechanisms of Injury—to ascertain if
other injuries may be present).
long bones, are highly vascular and highly innervated and once
broken are very painful and bleed a good bit. Now, throw in broken bone ends
ripping into the surrounding tissue, nerves and vessels and it’s a pretty
painful and dangerous combination.
Now, how do you treat it?
Running away screaming is not an option.
First, stop any life-threatening hemorrhage while you have someone call 911.
Do not try to push bone back into the skin. Next you want to immobilize, if
trained, the affected area with a splint of some sort.
The goal of splinting is to reduce pain and prevent further injury. The
splint may be something simple like an anatomical splint, ie. An arm
immobilized across the chest and secured in place with a sling and swathe.
It may be expedient like rolled up, duct-taped newspaper or cardboard or it
may be a commercially available splint like the SAM Splint, which is
extremely portable and lightweight.
The fx must be
splinted in such a manner so that the joint above and the joint below the
fx are immobilized.
CMS-Circulation, Motor Function and Sensation - Ask the victim
before splinting if they can wiggle their fingers/toes and if they have
sensation and do a quick capillary refill test. If the cap refill is less
than 3 seconds, good. If longer, this may indicate blood loss or impaired
If the extremity is cool and blue, it is extremely important to immobilize
the injured area and get to advanced care as quickly as possible.
Do not try to reposition in this case or in the case of a severely deformed
limb. Splint as is and get help quickly.
Once the splint is in place, check again for CMS.
If measuring a splint, measure on the unaffected limb for comfort.
If ‘binding’ a suspected rib fx, have
the victim inhale (it will be painful) as you secure the binding around
the ribs. Watch for any difficulty breathing or s/sx
(signs and symptoms) of shock as rib fx can lead to punctured
lungs, lacerated liver, splenic injuries or other internal
In the case of a skull fx (can be depressed or linear—meaning you will feel
a depression or you may not), check the level of consciousness and for any
clear fluid draining out of the nose or ears, bruising behind the ears or
under the eyes and get to advanced care quickly.
In pelvic, hip or femurfxlook
an abnormal turning outward or inward of the foot and the
injured leg may be shorter than the other leg due to the bone ends
overlapping one another and the muscle spasms which act as a natural
If you have any ice, place that on
the affected area as tolerated. Don’t
put it directly on the skin. Place some material between the ice
pack and the skin to prevent further tissue damage.
Keep the area elevated
to allow for drainage of blood/fluid and the prevention of swelling which
will lead to increased pain.
monitor the victim’s LOC (level of consciousness) and observe
for s/sx of shock and get to a definitive care facility as quickly
For more information, take a Dark Angel Medical 2 day non-live fire“Tactical
Aid Course” or a SIG Sauer Academy 3 day live-fire “Bullets and Bandages”
Recognize and Treat.
Immobilize, Ice and Elevate.
Until next week, stay safe.
SIMPLICITY UNDER STRESS
GET OFF THE 'X!'
Proper care while under fire and casualty evacuation (CASEVAC)
Tac Med Tip of the Week #13---9 March 2012
by Dark Angel Medical, LLC on Saturday, 10 March 2012 at 10:44 ·
OFF THE "X"!!! This is a term that many of us
are familiar with.
We're going to talk a little bit aboutproper
care under fire and casualty evacuationso that if the
time comes, there is no confusion on what to do.
What is the
"X" and why do we need to get off of it?
ACTIONS ON CONTACT (this description will
The "X" is the area in contact,
whether it's an ambush, several
active shooters or just
one active shooter and our
goal is to get out of that area as quickly and as
efficiently as possible while preventing ourselves, friends, loved ones
or team mates from sustaining any injuries.
the X and behind cover,
we must evaluate
any injuries sustained.
has been made and injuries
have been sustained:
contact with suppressive fire. This will allow the
casualty, if able to move, to move quickly
laterally out of the cone of fire and
where they can render self-aid.
many of you will know the difference between Cover
there are many who will not or have not yet received
provides protection from bullets, shrapnel, flying debris.
is something which will hide you but will not stop bullets
or any other ballistic threat!
ACTIONS (IA) ON CONTACT
1. SUPPRESS THE THREAT!!! The main concern at this point is not the
casualty but suppressing any incoming fire and neutralizing the threat.Mission accomplisment is
always primary. If this threat is not neutralized then you
increase the chance of sustaining more casualties and your team becoming
2. FIX YOURSELF!!! If you are
injured and can
still press your trigger, you
must have the proper mindset and continue
to lay down fire to suppress or neutralize the threat while moving to
cover in order to render self-aid.
3. FIX YOUR MATES!!!
If you can safely move to an
injured team mate who is unable to move themselves, move
to them under suppressive fire and evacuate
them to cover and begin
evaluating them and treating injuries as necessary.
Injuries, what are you looking for? Talk to them as
you approach them. If they're talking, yelling or otherwise, we
have Airway and Breathing
covered for the moment. If they are saying
that they're hit, then we also have a good assessment of their
neurological function as they are aware of what's going on. Use
all of this info as a baseline for further reassessments later. If
they are pulseless, not breathing and have no signs of life, move on to
the next victim.
What to do once the threat has been
neutralized and you are behind cover?
If you suspect
(cervical spine) or back
not move the casualtyunless
it is a life-threatening environment.
life-threatening hemorrhage and control it immediately.
Check Airway and
Look, listen and
feel for breathing.
color and temperature,
life-threatening bleeding occurs at any of these stages of assessment,
control it and then move back into your assessment.
neuro status of the vicitm.
Are they alert?
Do they respond to verbal stimuli,
painful stimuli or
are they unconscious?
Reassure the victim and give
Expose them and
check for further injuries and ensure that you re-cover them to keep
Watch for any
symptoms of rebleeding, mental status degradation or other signs and
symptoms of shock.
you have multiple casualties you must do the greatest good for the
fixate on injuries for which you cannot do anything and move on to
those whom you can help.
You must maintain the warrior mindsetthatyou will prevail and
will be accomplished.
you've been hit doesn't mean that the fight is over. It means that
the fight has just begun.
If shots are fired, learn to either hit the ground, assess
and return fire or
Run to nearest available cover, assess then return fire
If you have to leave cover to go help a downed buddy or to
link up, learn to ask yourself "what
am I heading to" and "where
is the next cover after that."
Learn to shoot from unusual positions on the ground as if
hit and fallen.
Jim Cirillo describes some of these positions (a note tbd)
You will be surprised at how different it feels to shoot
upside down, but as long as your marksmanship and safety
rules are followed, you will make clean hits.
initial reaction was to hit the ground because the first thing
you learn about combat is that anything standing gets hit." SGT MAJOR Franklin D. Miller,
MACV-SOG, MOH Recipient
Until next week, stay safe.
SIMPLICITY UNDER STRESS
(please click on this photo of the CST/FET soldier for a cropped closeup
of her loadout)
video of the CAT Tourniquet in a tactical situation
Dark Angel Medical, LLC
Alright folks, "Tac Med Tip of the Week":
Last week we talked about the importance of carrying two tourniquets (click).
This week we'll look at the function of the tourniquet.
life-threatening hemorrhage accounts for approximately 80%
of all combat deathswith
half of those being compressible either with a TQ or hemostatic agent.
The other half are non-compressible unfortunately.
A TQ, as we'll call it, enables the medic or person performing self-aid, to
quickly and efficiently achieve hemostasis
(stopping the flow of blood) from a compressible extremity injury. This will
hopefully, provided the wounded hasn't lost too much blood initially,
prevent shock and in the event of shock, hopefully prevent the shock from
progressing to it's irreversible stages.
The TQ works best
when placed as high as possible on the affected limb on a single long bone
(ie. the humerus in the upper arms or the femur in the upper legs) The
rationale behind this is that as the windlass is turned to compress the TQ
material, it is compressing all the vessels against the large surface area
of those long bones and this aids greatly in stopping the loss of blood.
Once the flow of blood has been stopped, it
is imperative to monitor and reasses the casualty and site of injury every
5 minutes until the casualty has been delivered to a higher level of care.
The reason for this is to ensure that they are not exhibiting nor
experiencing any signs or symptoms of shockand that the
flow to the affected limb remains stopped. As we talked about last
week, if the TQ isn't on tight enough to
compress the arterial flow but cuts off the venous flow, not only
does the casualty lose precious volume but also
can build dangerous high pressure in the extremity and what may not have
been a "loss of limb"
situation with a properly placed TQ, now is due to compartment syndrome
damaging the nerves, tissue and vessels.
Remember, the TQ is
not the last resort any longer and they can stay on safely and
effectively without any adverse effects, or LOSS OF LIMB, for
up to 2 hours and in some rare cases, even longer, per recent
Put the TQ on like a military
haircut; high and tight.
Reassess your casualty every 5
check for shock
ensure there is no bleeding
Know your equipment. Practice with
You want to get it on, tightened enough to stop ALL arterial flow and
secured in an ideal situation in less
20 seconds. Shooting for 15 or less than 15 is best. Buy a
'training' TQ and work with it on all extremities. Dominant and
non-dominant hand. After applying it check for a pulse. Consider this "Medical
This is a top-level instructor (SFOD-D) a fantastic idea
Alright folks, "Tac Med Tip of the Week" time:
This week's tip: Always
carry two tourniquets which are readily accessible on your kit/equipment.
This could mean having one on your plate carrier or pocket and one on your
kit. If your kit comes with a TQ, buy another. Why? One, the saying, "Two
is one, one is none."..comes to mind. Also, sometimes
takes more than one TQ to achieve hemostasis. Placing on TQ right
above the other will double the surface area being covered and compressed
and will increase the chances of increasing hemostasis. Remember, a poorly
place TQ can be extremely dangerous. It can not only cause problems from
loss of volume but also the build up of fluid and pressure in the tissue
compartments and possibly cause Compartment Syndrome.
Know your kit. Practice with your kit. Simplicity Under Stress.
where the important vascular/arterial pressure points are!CLICK
Tac Med Tip of the Week #5-6 Jan 2012
by Dark Angel Medical, LLC on Monday, 9 January 2012 at 18:18 ·
Hey everyone, just got in from work and wanted to get this week's "Tac Med
Tip of the Week" up for you!
This week we'll cover an often overlooked, yet invaluable piece of kit in
our D.A.R.K., the pressure bandage.
In our case, the Emergency
Bandage a.k.a. Israeli
Bandage. The pressure bandage has been around for a while and has
seen it's development stem from the old gauze field dressings of old...and
if you've ever carried an M3
bag, then you know exactly what we're talking about!
A tourniquet is top notch kit for a
compressible, life-threatening hemorrhage and hemostatic
agents are great for anything from superficial lacerations to
deeper penetrating injuries and these tools work great but are pretty much
suited for just one purpose each.
Emergency Bandage is a pretty versatile piece of kitin
that it can do a lot of things and it doesn't take up a lot of room.
You can utilize it as a standard pressure dressing on a wound that is easily
controlled with direct pressure so that it
frees up your hands to take care of more important matters (ie.
treating more patients or having one or both hands on your weapon and
neutralizing a threat).
Its 'pressure bar' is pretty unique as it directs around 30 lbs of focused
pressure directly over the wound. Tightened
and you can achieve a tourniquet effect.One
of the keys to success is how you wrap it.
As you are wrapping it, stretch
it out as you go around the extremity. This will add increasing
pressure and will get tighter as you go. Something else you can do is, after
the injured area is covered, wrap
one or two wraps above and one or two wraps below the area while wrapping
and then continue on directly over the injured area. This assists
in keeping the dressing centered over the wound, thus keeping the pressure
focused where you want it.
Since you can get the TQ effect, make sure
you continously monitor the extremity for circulation, movement and
sensation by having the victim wiggle their fingers, check the color and
temperature of the skin and ask them if they can feel their fingers.
Reassess every 5 minutes to monitor for
rebleeds as well.
If it continues to rebleed and turns into a life-threatening hemorrhage, consider
the use of a TQor
if non-life threatening, consider
the use of utilizing a hemostatic plus the pressure bandage.
Another couple of functions of this
versatile piece of kit are a dressing for
a head wound or even a stump
dressing for an amputation because it provides great axial
Now, to use this little bandage, you don't
necessarily have to be bleeding either because it has the elastic
properties of an ACE-style bandage.
You can use it to swathe an arm to the upper body for an anatomical
splint, bind suspected broken
ribs, put direct pressure over an
occlusive dressing to the chest or abdomen,
help stabilize a flail
chest (see also) or even assist
in splinting lower extremity injuries to reduce the pain or chance
of increased injury.
Also, if you don't have your D.A.R.K. on you (shame on you), you
can always use a field expedient method by using gauze and
an ACE-style elastic wrap to attempt to achieve similar results.
Use what you have on hand and do the best you can. Improvise.
Adapt. Overcome. So, there you have it. The little dressing with
big potential. Think of it as the icing and your injury as the cake. The
cake may be okay but the icing makes it so much better!
We'll go over wound packing this week to piggyback on the last two weeks
where we talked about tourniquets.
Wound packing can basically be divided into a few separate simple steps:
Expose 2) Identify 3) Pack 4) Wrap 5) Reassess
In any injury, you
first need to expose the victim to evaluate and identify the wound(s) and
inspect for any additional wounds.Remember,
wounds are "distractors" meaning they may look worse than they are and
therefore distract us from other, more severe, yet less obvious injuries.
Once you have assessed the injury, you will
then need to identify the source of the bleed. There are a couple
of methods to utilize, the "scoop method"
or the "blot method".
The "scoop" method is where
you would literally scoop blood out and away from the wound cavity while
"blot" method, you take a
piece of gauze and blot the wound, which soaks up the blood, pull
the gauze away and identify the bleed.
Now comes the packing.
To effectively pack
a wound, you must pack the wound as tightly as possible toward the bone
while filling the entire wound bowl with even concentric pressure in order
to acheive hemostasis. Again, the bone acts as a "backer" while the
gauze can compress the vessels--like in the tourniquet.
To do this, one of the easier
methods is to feed gauze from the package
(instead of taking it out of the package which risks additional
contamination) from your non-dominant handinto your dominant
hand and push the gauze into the
wound channel/cavity with your index
goal is to get even pressure throughout the wound.
wounds can be deceiving, especially ballistic
injuries in that they may have an
extremely large temporary cavity that will displace easily and require a
good deal of packing material.
Image showing examples of temporary cavity in tissue created by bullets of
Blast injuries may have varying
levels of tissue injury and multiple
from shrapnel and it
may be difficult to ascertain where to pack.
Pack these the same way. ID the
bleed and pack. If there is a through-and-through
injury, pack from the
front-to-back to the bone and vice versa.
pressure on the wound for at
least 5 minutes or until all visible bleeding has stopped.
If there is any additional packing material
left over, fold it over and place it on top of the wound and then
move on to the wrap.
Wrapping over the wound with a pressure
dressing and applying direct, focused pressure is key in achieving
hemostasis. Place the gauze portion(s) of the dressing over the
wound and with
each wrap, pull the dressing tighter. This will increase
the level of pressure on the wound and packing material.
Once the wrap is done, secure
it in place and reassess the
victim at least every 5 minutes to monitor for any rebleeding or
change in the victim's mental status or any other signs and symptoms of
Note: We have purposely not talked
about various packing materials or pressure dressings as this will be
discussed in future installments.
It's something that can be practiced on a wound simulator, a pork shoulder
or any other piece of meat and like anything, practice makes perfect.
Treat a wound like your rucksack: Pack
full and wrap it tight.
Until next week, stay safe.
Simplicity Under Stress. 2.
It's Friday and that means it's "Tac Med Tip of the Week" time. Last week,
we covered the importance of wound packing. Today,
we'll go over some ways to attempt to open, stabilize and maintain a
life-threatening hemorrhage, breathing injuries (injuries to the thorax)
are the most common cause of combat-related deaths, with airway
injury fatalities holding a small percentage.
However, if the airway isn't evaluated and one moves on to the obvious,
distracting breathing injury, treating that thorax injury won't do any good
if the airway isn't patent. Right?
So, let's talk about how to address those airways. First
off, if someone is yelling or screaming, their airway and breathing
are intact for the time being but must still be addressed in a brief survey
of the victim's overall condition. If the victim is not yelling, moaning or
otherwise making any noise, the condition of the airway is unknown
and must be evaluated immediately after checking for any life-threatening
Check breathing and airway!
There are a couple of elements which can come into play here such as do
have a suspected C-Spine
injury or not?Did
anyone witness them fall to the ground? In the interest of time and
in keeping this article brief, we will address this a witnessed injury with
no c-spine injury being incurred.
The main thing to concentrate on is
evaluating and treating the victim as quickly as possible and moving them
out of the 'beaten zone' to a more secure area
in which to further evaluate and monitor them. Life over limb is the most
When you reach the victim and
check their level of consciousness, you can look
at the chest for rise and fall and listen for any noise in breathing.
Opening the airway
is fairly simple. With the victim on their back, take one hand and
place it on the forehead of the victim while 3-4 of your fingers on your
other hand go under the jaw on the the side closest to you and you press
down with the hand on the forehead and pull up with the fingers under the
jaw. This motion will hyperextend the neck and pull the tongue off of the
back of the airway allowing it to open.
The main disadvantage to this in a
tactical situation is having both hands
off of your weapon. Once
the airway is open you can maintain the airway through the use of a basic
airway adjunct like the nasopharyngeal (NP) airway.
Tactical hint:Practice slinging your primary weapon
(e.g. M4, Shotgun) to "Climb and Carry" which is also good for dragging a
buddy out of a position under fire or imminent danger. Equally
important is practicing smoothly,
efficiently and quickly
bringing the weapon into battery because Suppression
of enemy fire and Situational Awareness is critical!! If
the team medic is taken out of action everyone's life is at a greater
of transition drill which may be used to free the hands. (soldier with blue cap has carbine slung in one of the climb and
carry positions leaving hands free)
To place this airway, measure the nostril size compared to the airway size
or just look at the victim's little finger and it's usually the same size as
Measure the length from the tip of the nose to the anlge of the jaw or
earlobe. Insert the airway straight down after 'pig-nosing' the victim
(pulling the nose back and up) with the bevel (the angled edge) towards the
septum(dividing cartilage) and keep going until the flange is resting
against the nostril.
Lubrication of the NPA can be with lube, if available, or even blood or
saliva (the victim's, not yours!)If you meet any resistance, don't force it,
utilize the other nostril. Once in, the victim should have a patent airway.
I decided to try inserting an NPA on myself.
It's important to remember that if the victim has massive head and
facial injuries to not use this airway as there could be fractures of
the skull and the airway could cause more harm than good.
Image: Not a good situation for an NPA. DOA result of no airway.
At this point, place the victim into the recovery
position on their side with the head angled towards the ground.
This allows gravity to assist in maintaining a patent airway by pulling the
tongue forward and not occluding the NPA as well as allowing for blood or
other fluids to drain out of the mouth.
Reassing and monitoring of these victims must
be done at least every 5 minutes.
Simple airways are just that, simple. Anything else must be done by an
advanced care provider.
So, check the
airway, open the airway, stabilize the airway and maintain/evaluate the
There's a lot of info here and hopefully you'll never have to use it but
having that knowledge in your toolbox is of the utmost importance.
The NPA; Measure it, lube it, Insert it. Don't force it.
In the past weeks we've touched on a couple of hemorrhage-related issues
like TQ application and wound packing.
Today we'll go over what we may expect to see, hear or feel or what our
victim may feel if we have a case of hemorrhagic shock.
There are several types of shock but the one we will be going over today is
Basically, it is caused by blood being lost too rapidly for the body to
"keep up" or compensate for the loss. We'll get into that shortly.
Think of it like this:
we're talking about shock, think of our body as a hydraulic system. You've
got the pump (Heart), the tubing/hoses (the vessels) and the fluid (blood).
If you've got a problem with one of the three, it's not good but if you have
a problem with two of them or, in the worst case scenario, all three, then
you're done and the machine fails to function. In this case, the machine is
The average size man (I use man here not being sexist but from a research
standpoint) has between 5 and 6 liters of blood. There are approximately
500ml per unit which equals 2 units per liter. An
individual can go into shock by losing as little as 1/5th of their
circulating volume or even less. Then there are children, who
having a much smaller circulating volume, can't afford to lose much at all.
The Stages of Shock
So, having talked about what hemorrhagic shock is and how much blood we can
lose, we'll get into the 'staging'
of shock and some of the signs and symptoms. Quick note: a "sign"
is objective, meaning it's something that you as the rescuer will see while
a "symptom" is subjective, meaning it's what the victim feels.
So we're going to cover the staging of shock. Depending on what lessons you
cover, there can be three stages, four stages or five stages. We’ll stick
with the four stages set forth by Advanced
Trauma Life Support.
In Stage I,
the body is able to keep up with the blood loss due to the natural defense
mechanism of maintaining homeostasis (balance). The body has lost
approximately 750ml (1.5 units) of
blood during this stage and the vital signs are essentially unchanged. This
is due to the vasoconstriction (contraction of the blood vessels) in the
body to decrease the diameter of the vessel, which decreases the inner lumen
(opening) of the vessel which increases the pressure which ensures all
tissues are adequately perfused. You may see a slight elevation in heart
rate at this point as the “pump” is working with less volume and trying to
do the same job as it was before the injury was incurred. To keep things in
perspective, if the femoral artery is dissected, it can lose a little over a
liter of blood in 60 seconds or less.
When the victim has lost between 750ml-1500ml,
they’ll be entering into Stage
IIof shock. The body is no longer able to compensate for
the blood loss and the machine is failing. You may see and feel pale, sweaty
skin, increased heart rate (over 120 beats per minute), decreased blood
pressure (less than 100 systolic –the top number) and decreased capillary
refill and increased respiratory rate (which is the way the body is
attempting to ‘fix’ itself by blowing off excess waste products, which if
not expelled will lead to a potentially fatal state known as acidosis,
which is an upset in the body’s delicate pH balance).
You should be able to feel a pulse at the radial artery on the wrist (which
indicates BP > 80 systolic). Let’s talk about cap refill for a second…Capillary
refill is a simple yet effective way to check perfusion status of
the victim. To check cap refill, ‘blanch’ the victim’s fingernail by
pressing it until it turns white, then let go. In a normally perfused
person, the nail bed should turn pink in less than 3 seconds. Anything
longer could indicate a perfusion issue. Also, other good areas to look for
adequate peripheral perfusion are the gums, the lips and the conjunctiva of
the eyes (pull the eyelids down and see if they’re pink or white) Pink is
good, white is bad as it indicates a shunting of blood to life-preserving
In this stage of shock the victim may also be complaining of feeling anxious
or nauseated and may vomit. They may also have an altered mental status.
This is indicative of inadequate perfusion of the brain. The brain is greedy
and loves blood, oxygen and glucose and needs good blood pressure to ensure
it is perfused appropriately. Also, please ensure airway is secure at all
In Stage III,
the victim has lost up to 2000ml (that’s
liters!) and will be in dire straits unless treated promptly. The BP will be
less than 100 systolic, the heart rate will be 120 or greater, the skin will
be cool and clammy with decreased cap refill and they may be in and out of
Once the blood loss has reached greater
than 2000ml (half or more than half of the circulating volume) the
victim is in Stage
IV of shock where death is imminent unless extremely aggressive
resuscitation is attempted and even then, the chance of survival is marginal
at best. The signs of this stage of shock are heart rate greater than 140
per minute, blood pressure less than 70, which means one
could only palpate a pulse at the carotid artery in the neck and
there would be absence of cap refill. The skin will be extremely cool to
touch and the victim may be unconscious and the respiratory rate would be
greater than 40 per minute, shallow and irregular.
Shock, if not treated, can lead to a downward spiral.
Excessive blood loss leads to coagulopathy
(impaired clotting ability due to loss of important clotting factors),
acidosis (body becomes acidic due to excess waste by-products as the body’s
natural ability to remove them has been damaged through the loss of blood)
and hypothermia (the body is unable to maintain normal body temperature)—hypothermia
can also be sped up through external environmental factors as well and leads
to increased coagulopathy, which leads to acidosis,
which leads to impaired ability to maintain normal body temp—the downward
spiral also called the “Triad of Death”.
Now that you hopefully have a good understanding of what hemorrhagic shock
is and how to recognize it. How do we treat it?
First , the
bleeding MUST be controlled and stopped by the best means necessary. The
faster the bleeding is stopped, the less blood they lose. The less blood
they lose, the less the chances are of them going into shock, the better
their chances of survival. Once the bleeding is stopped, assess the victim
and ascertain the MOI (mechanism of injury). This can tell where the injury
may be in the body (ie. Liver, spleen, kidneys—which all bleed quite a bit).
replacement is next and in the first two stages of shock, oral
fluids can be administered IF the
victim isn’t vomiting or doesn’t have a penetrating abdominal injury. Some
good choices are ORAL IV or Oral
Replacement Salts. IV fluids like
normal saline or lactated ringers are ok, volume expanders such as
Hextend or albumin
are good but packed red blood cells are
the best as that’s what the body has lost and needs replacing.
IV fluids must also be administered judiciously as the overdilution of the
blood can dilute the clotting factors and disrupt the clots which have
already formed and lead to a fatal, uncontrollable hemorrhage.
Basic care of the shock patient after hemorrhage control is keeping them
warm (remember cover them completely after exposing, assessing and treating)
and also elevation of the lower extremities 12”
above the level of the heart unless there is a head injury (which could lead
to dangerous pressure build up in the brain). The elevation of the legs
helps to keep the blood perfusing the brain and other vital organs like the
liver, kidneys and intestines (Trandelenburg
More importantly is constant monitoring and reassessing the victim at least
every 5 minutes until they are evac’d for any changes in mental status or
any visible signs of a rebleed.
While shock is comprised of many factors, the treatment is relatively
simple. Know the signs and symptoms, know how to treat them and know your
kit. This has been a longer than usual tip but I feel it extremely important
not only to know how to treat something but the rationale behind the
treatment and how/why things happen.
Bleeding stopped, keep ‘em warm, legs up.
Until next week, stay safe. SIMPLICITY UNDER STRESS
Kerry Davis Dark Angel Medical
Tac Med Tip of the Week #11--17 Feb 2012
by Dark Angel Medical, LLC on Friday, 17 February 2012 at 15:06 ·
You're driving to the range, sipping your coffee one cold morning
and all of a sudden the car in front of you blows a front tire,
loses control and wrecks. You pull over, call 911, grab your
D.A.R.K. and head over to this mangled pile of metal that less than
a minute ago was an automobile. The driver miraculously gets out of
the car yelling for help waving at you with both hands. The only
problem with that is that only one of the hands is attached to his
body and he's losing a lot of blood.
What do you do?
So, we're now dealing with a traumatic
amputation and the very real possibility of this person bleeding to
death from a massive hemorrhage. At this moment, the most
important thing is to stop the bleeding. Utilize the TQ in your
D.A.R.K. Put your
gloves on and apply the TQ high on the affected limb so that it's
compressing the artery against the long bone in the upper arm, the humerus.
Tighten it until ALL of the bright red bleeding stops.
The victim is talking to you and is alert and conscious so you've got
airway, breathing and circulation covered. Look them over carefully for any
other injuries and utilize the other kit portions as necessary. Ask them if
they remember what happened, what day, month and year it is (assessing his
state of consciousness). Monitor and reassess the TQ to ensure it's tight
and utilize the
Emergency Bandage to dress the stump. Continue to monitor and
assess the victim for any changes. Since it's cold outside, get a space
blanket or something underneath them and cover them up to prevent
hypothermia and monitor for signs and symptoms of shock.
(See the Tac Med Tip on Shock).
Now, what do we do with the amputated body part? First, it's cold outside,
so that's actually a good thing as it slows down cellular metabolism and
helps preserve tissue. Get
the hand, wrap it in a towel you grabbed out of your trunk, douse the
towel with your bottled water and slide it into the gallon-sized ziploc
bag that held your sandwiches in the cooler for the day. Close the bag
securely and place that bag in the cooler on top of the ice while you wait
for EMS to arrive.
Never put an
amputated or degloved body part directly on ice as that kills the
tissue. However, wrapping the part in a moist cloth and putting it into a
plastic bag and putting that on ice can increase tissue viability up to 12
Control any life-threatening hemorrhage.
Check for any other injuries and monitor mental status.
Watch for and treat any signs and symptoms of shock.
Tac Med Tip of the Week #7--20 Jan 2012
by Dark Angel Medical, LLC on Friday, 3 February 2012 at 20:19 ·
And now, for the long-overdue Tac Med Tip of the Week.
Since it's winter, we thought it would be wise to go over some basic
precautions and things to look out for when out and about in cold temps. We
prepare for the shootouts and trauma but in many cases, the environment is
our biggest enemy and it's one fight that's pretty easy to win with some
good, solid planning and keeping a level head.
The first thing is remaining dry. Cold and dry, not a big deal. Cold
and wet sucks and it's pretty dangerous. Layer up in wicking
clothing that breathes and doesn't trap moisture. Cotton
traps moisture, things like Patagonia's Capilene doesn't. Good
boots and socks are also essential. Get a pair of gaiters
as well to keep your pants from getting wet.
is still one of most effective clothing which retains its ability to
insulate when wet.
Bring extra clothing and socks in your ruck. Another
good preventative measure is properly hydrating. The average person
loses around 1.5 L of
water every day in 'insensible loss' (passive) just through respiration.
Cold weather tends to make us want to drink less also, plus it inhibits ADH
(anti-diuretic hormone), the hormone responsible for 'water-handling' so we
tend to urinate more.
insensible loss, decreased intake of fluids by mouth and increased
urination and you're heading down a hard road in a hurry.
Plus, remember, from the Shock
segment last week, cold weather also inhibits clotting, so if you're
dehydrated already, you're fluid reserves are low and if you get wounded,
you're going to be deep in the hurt locker.
Alright, so what are the cold injuries and
how do I recognize them?
Well, we'll start with 'frostnip'.
Frostnip is basically a minor, localized cold injury to areas of the body
with decreased circulation (ie. ears, nose, fingers, toes). The area can a
have a reddened or even a pale appearance and will be painful (pins and
needles feeling). Think of how bad it hurts when someone thumps your cold
ear! Well, how do you take care of it?
First, get out of the cold and start
rewarming the affected area. It'll usually recover pretty quickly provided
exposure isn't repeated multiple times.
If that happens, you can find yourself with a case of mild frostbite which
can progress to severe frostbite.
How can you recognize frostbite?Frostbite
is literally frozen tissue and can be similar to a burn in that it can be
superficial in which the skin will blister up and slough off and repair
itself after a few weeks or deep in which case the tissue is dead, can necrose
(rot) and cause serious infections, loss of digits/limbs and death.
How can it be treated? Get out of the cold! Do not attempt to rewarm the
affected area until you are in a treatment facility and wrap
it in loose gauze, much like you would a burn. Don't
allow the injured areas to rub against one another as this will damage the
One last type of cold injury to be on the lookout for and is easily
preventable, is hypothermia.
Hypothermia can set in rather quickly and you need to know the symptoms and
what to do in case you see it. Mild
hypothermia is characterized by a body temp of 93-95
F and the victim will have uncontrollable shivering (this
is the body's attempt at rewarming). Get them out of the cold, into dry
clothing and give them warm liquids by mouth--nothing with alcohol as it can
actually make the hypothermia worse.
The next couple of stages gradually have
the person acting lethargic and drunk to actually feeling hot and taking
off the clothing to lying down to rest. Their temps at these stages
run from 85-92 F. Their
skin will be pale or have blue-tinged lips or nail beds and be cold to
All of these symptoms show that the body has lost the ability to rewarm
itself and you must act quickly. Again, get them out of the cold and rewarm
Watch their level of consciousness and
protect their airway. But warming them back up is imperative. Even
if it means getting them out of their clothes and into a sleeping bag and
crawling in with them, it's their life at stake. Their are several pieces of
great kit out there like the Blizzard
Blanket that are great at keeping folks warm while being
Another alternative is to make a 'tee pee'
out of a space blanket, wrap it
around yourself and the victim and put a
candle on the ground between you and you've made yourselves 'baked
potatoes' and you will warm up quicker than you think and also help dry out
wet clothing. Also, if the situation allows, build as large a fire as is
safe and utilize it's heat to rewarm,
dry out and make
some warm liquids to warm your core.
So, be prepared,
hydrate, stay dry and get out of the cold.
Until next week, stay safe. Simplicity Under Stress
We've talked about many different things which can be immediate,
life-threatening problems and how to fix them in a reactive manner. Today
we'll talk briefly on some pro-active measures which can help both rescuer
An often overlooked component in the training environment is overall
Taking the time to ensure you are fit is beneficial in many ways.
If you're fit and healthy, it
can increase your survivability as your body is used to being
'stressed' in strenuous exercise sessions and it will increase your stamina
which can help you help others in care under fire or other events in which
you may need to move one or more casualties to safety and still have the
energy to triage and treat them.
One of the first things you can do for yourself is to ensure you're properly
The majority of folks walk around daily
with mild dehydration. Always "top off your tanks" anytime you get
the chance as you never can tell what may happen.
If your urine
isn't clear, it's a good sign you may be slightly dehydrated.
Another thing is proper nutrition. Lots of protein, fresh veggies and
complex carbs! Steer clear of simple sugars and processed foods.
Nutritional supplementation is also a very important thing but ensure that
the supplements you take are of the highest quality (we
take Shaklee supplements...good stuff).
Plenty of sleep is another factor in
overall health as well. We 'repair' when we're sleeping, so getting a good
night's rest is extremely important in our fitness regimen. It helps keeps
alert and promotes good situational awareness.
Our fitness routine is extremely important as it needs to mimic our daily
lives. We say "Train
like you fight." Well, "Work
out like you move." I like to call it "Functional Fitness".
Lots of conditioning and multi-joint exercises which mirror how we actually
move or may move under stress.
Gaining strength while gaining flexibility is a key in injury prevention.
Matt Gibson, owner of Gibson Strength in Boulder, CO, says that "many people
That overtraining can lead to more injuries rather than preventing them.
Three to 5 sessions per week with a good
warmup of at least 7-10 minutes,
emphasis on core exercises, as the core
supports your back, abs and obliques, and
high repetition exercises with lower
weights or exercises which incorporate your body weight.
Follow up with at least 20 minutes of
some low-impact cardio to help boost your metabolism.
Know your limitations (pre-existing conditions), have a physical exam done
prior to engaging in a new exercise routine and start out slowly and work
your way into the new routine.
Maybe even consult a reputable trainer to help build a custom workout plan
for you based on both your needs and limitations.
Make the time to stay fit just like you make the time to hit the range or
take a new class. We are committed to helping others and must make the same
committment to help ourselves. Ensure you
allow for proper recovery as well. Hydration, post-workout
supplementation, sports massage and rest all help but make
sure you take a couple of days off to allow your body to sufficiently rest
and recover. Kat's hints:
I did long distance running, I found that dehydration and not
understanding the importance of recovery time were common among avid
runners. If you are tired and need the recovery time yet continue to
train, we'd call the running/intervals/sprint training "Junk
Miles" because they would
tear you down more than build you up. In fact, serious runners plan
their training schedule with recovery days especially before races.
The very same thing would be true of weight/strength training when people
would exercise one muscle group more frequently than three days per
Some of the signs of overtraining are increased heart rate when you wake
up in the morning and a vulnerability to injuries. For runners, shin
splints are a sure sign of either overtraining or stepping up the
difficulty/speed. Professional and pre-professional ballet dancers
commonly train in a dehydrated and malnourished state. One of the
first signs of dehydration as Pocket Doc said is dark colored or almost no
urine. Another sign is muscle
cramps and knots. Ignore the common advice of increasing or
adding potassium supplements at first. That advice originally came
from companies and natural food stores who need to make a profit.
The more fit one becomes, the more dilute your perspiration is in
electrolytes thus conserving them in your body.
One sure way of getting your body to a hydrated state is to drink enough
water (not caffeine containing drinks, since that is a diuretic) that you
have to urinate twice in a row. Also remember that if you are
dieting to lose weight, in a
starvation diet, half the weight you lose is muscle tissue.
In extreme cases, women are particularly vulnerable to heart problems as a
This is just a framework. Build on it, customize it and make it
Get plenty of sleep.
Eat your vitamins.
Exercise like you move.
Rest and Recover.
Care in the field is only half the battle. You
have to care for yourself first and be healthy and fit before you're
able to care for someone else.
Until next week, stay safe. Simplicity
Today we'll talk about a condition typically known as a "sucking
What is a Sucking Chest Wound?
The 'sucking' comes from the sound the wound makes as air is drawn in
and out of the thorax.
How the lungs work
The chest/thorax is essentially a closed system with the trachea being
the only opening. Respirations are affected by the diaphragm contracting
and flattening out which expands the chest and creates negative pressure
in the chest cavity and draws air into the lungs, thereby equalizing
pressure. Think of it kind of like a bellows used to fire a forge. As
the pressure is equalized, oxygen and waste are exchanged, oxygen goes
into the blood to be distributed throughout the body and the waste is
expelled in the form of carbon dioxide during exhalation.
Basically, the sucking chest wound is
a simple pneumothorax, which is when the thorax is penetrated
by shrapnel, bullets or other penetrating trauma (in this case) and air
is allowed into the chest cavity through the hole, thereby collapsing
What are the symptoms?
injury to the thorax (entrance/exit wounds) with
(rapid, shallow breathing),'sucking
with pinkish-bloody frothy bubbles coming out of wound,
rise and fall of the chest,
of movement on the affected side or
absent breath sounds on the affected side (for those who carry and
use a stethoscope).
What needs to be done? This
an immediate treatment injury. An occlusive
dressing needs to be applied and the casualty needs to be
monitored for the development of a tension
pneumothorax--which we'll get to shortly.
An occlusive dressing can be
anything airtight which covers a
border of 2" outside the wound. You many not always have HALO
Seals on hand, so anything that can be
airtight needs to be applied, yes, even duct
tape and a plastic wrapper
will suffice. In this instance, thinking
outside of the box is critical.
life threatening hemorrhage,
the dressing over the wound and secure it in place.
Now, something extremely
important to remember is to check for any exit wounds as well
as they will need to be dressed as well.
There has been some controversy over 3 or four sided dressings. We
a four sided dressing as it is more realistic in a
non-permissive environment and you will be monitoring the casualty for
any signs and symptoms of a developing tension pneumo as well.
Also, positioning of the patient has been questioned (affected side
down/affected side up) and based on feedback from providers in the
advocate affected side down as the injury will involve
hemorrhaging as well and it is best to leave it in a dependent position
so as not to impede oxygenation with the unaffected side.
Also, it can be the provider's call in
the field to position the casualty in the position which increases
both comfort and ability to oxygenate easier.Recovery
position works well and it aids in maintaining a patent airway.
As the casualty is monitored,
any increased difficulty in breathing,
around the lips or skin
the worst-case scenario, the trachea is actually deviated (pushed
away) from midline.
heart rate will be extremely elevated as well as the respiratory rate.
This is a tension
pneumothorax and it will prove fatal
unless rapidly treated. This
can be very insidious and take some time to occur, sometimes up
to 2 hours or more.
Post-Mortem tension pneumothorax
resulting from severe blunt trauma
showing the classic features:
the trachea away from the side of the tension
Shift of the mediastinum.
Depression of the
Even if the casualty has a properly placed occlusive dressing on the
wounds, air can still enter the thorax
via the trachea and the injured lung, thereby increasing
pressure in the thorax until it pushes the heart and great vessels over
to the uninjured side and compresses them and the uninjured lung,
compromising both the ability to oxygenate and pump blood and
will lead to death.
How is the tension pneumo treated?
"Burp" the occlusive dressing if possible by having them exhale as you
lift up on an edge. There may be a 'rush' of air and possibly blood as
it leaves the pleural space and they
will have almost immediate relief and breathe easier.
Another method, advanced
practice only, is the needle
decompression in which a 14 gauge or larger needle is inserted
into the thorax at a specific level (typically the 2nd Intercostal space
over the rib) and releases the air buildup. The disadvantage
to this is that the smaller gauge catheters can collapse or plug and the
casualty will require mulitple decompressions.
The most effective way to relieve and
treat this is with a chest tube placement, which would
typically be done in a Forward
Surgical area by a Physician
or PA or in the field (worst
case scenario) by the medic, if trained, in order for the lung to
re-expand and surgery to be performed to treat and alleviate any other
Sucking chest wounds suck, literally and figuratively but with rapid,
efficient treatment, you can buy the casualty some valuable time, keep
them in the fight and ulitmately save their life.
Seal the front,
check the back.
Until next week, stay safe.
VIDEOS illustrating the Sucking Chest
Video: What a sucking chest wound can look like:
movie "Three Kings," Warner Brothers, released Oct 1, 1999 and one of
the best animated descriptions of a chest bullet wound pneumothorax
Tension pneumothorax is the progressive build-up of air within the
pleural space, usually due to a lung laceration which allows air to escape
into the pleural space but not to return. Positive pressure ventilation
may exacerbate this 'one-way-valve' effect. Progressive build-up of
pressure in the pleural space pushes the mediastinum to the opposite
hemithorax, and obstructs venous return to the heart. This leads to
circulatory instability and may result in traumatic arrest.
The classic signs of a tension pneumothorax are deviation of the trachea
away from the side with the tension, a hyper-expanded chest, an increased
percussion note and a hyper-expanded chest that moves little with
respiration. The central venous pressure is usually raised, but will be
normal or low in hypovolaemic states.
However these classic
signs are usually absent and more commonly the patient is tachycardic
and tachypnoeic, and may be hypoxic. These signs are followed
by circulatory collapse with hypotension and subsequent traumatic arrest
with pulseless electrical activity (PEA). Breath sounds and percussion
note may be very difficult to appreciate and misleading in the trauma
Tension pneumothorax may develop insidiously, especially in patients with
positive pressure ventilation. This may happen immediately or some hours
down the line. An unexplained tachycardia, hypotension and rise in airway
pressure are strongly suggestive of a developing tension.
This post-mortem film taken in a patient with severe blunt trauma to the
chest and a left tension pneumothorax illustrates the classic features of
Deviation of the trachea away
from the side of the tension.
Shift of the mediastinum.
Depression of the
With this degree of tension pneumothorax, it is not difficult to
appreciate how cardiovascular function may be compromised by the tension,
due to obstruction of venous return to the heart. This massive tension
pneumothorax should indeed have been detectable clinically and, in the
face of haemodynamic collapse, been treated with emergent thoracostomy -
needle or otherwise.
A tension pneumothorax may develop while the patient is undergoing
investigations, such as CT scanning (image at right) or operation. Whenever
there is deterioration in the patient's oxygenation or ventilatory status,
the chest should be re-examined and tension pneumothorax excluded.
CT of tension pneumothorax
The presence of chest tubes does not mean a patient cannot develop a
tension pneumothorax. The patient below had a right sided tension despite
the presence of a chest tube. It is easy to appreciate how this may happen
on the CT image showing the chest tubes in the oblique fissure. Chest
tubes here, or placed posteriorly, will be blocked as the overlying lung
is compressed backwards. Chest tubes in supine trauma patients should be
placed anteriorly to avoid this complication. Haemothoraces will still be
drained provided the lung expands fully.
The CT scan also shows why the tension is not visible on the plain chest
X-ray - the lung is compressed posteriorly but extends out to the edge of
the chest wall, so lung markings are seen throughout the lung fields.
However there is midline shift compared to the previous film.
Initial chest film
After chest tube insertion
Upper thorax showing
position of chest tubes
Tension pneumothorax may also persist if there is an injury to a major
airway, resulting in a bronchopleural fistula. In this case a single chest
tube is cannot cope with the major air leak. Two, three or occasionally
more tubes may be needed to manage the air leak. In these cases
thoracotomy is usually indicated to repair the airway and resect damaged
Beware also the patient with bilateral tension pneumothoraces. The
trachea is central, while percussion and breath sounds are equal on both
sides. These patients are usually haemodynamically compromised or in
traumatic arrest. Emergent bilateral chest decompression should be part of
the procedure for traumatic arrest where this is a possibility.
This (rare) chest X-ray shows the characteristic apparent 'disappearance
of the heart' with bilateral tension pneumothoraces.
Bilateral tension pneumothoraces
Classical management of tension pneumothorax is emergent chest
decompression with needle thoracostomy. A 14-16G intravenous cannula is
inserted into the second rib space in the mid-clavicular line. The
needle is advanced until air can be aspirated into a syringe connected
to the needle. The needle is withdrawn and the cannula is left open to
air. An immediate rush of air out of the chest indicates the presence of
a tension pneumothorax. The manoeuver essentially converts a tension
pneumothorax into a simple pneumothorax.
Many texts will state that a tension pneumothorax is a clinical
diagnosis and should be treated with needle thoracostomy prior to any
imaging. Recently this dogma has been called into question. Needle
thoracostomy is probably not as benign an intervention as previously
thought, and often is simply ineffective in relieving a tension
pneumothorax. If no rush of air is heard on insertion, it is impossible
to know whether there really was a tension or not, and whether the
needle actually reached the pleural cavity at all. Some heavy-set
patients may have very thick chest walls.
Needle thoracostomies are also prone to blockage, kinking, dislodging
and falling out. Thus a relieved tension may re-accumulate undetected.
More importantly is the possibility of lung laceration with the needle,
especially if no pneumothorax is present initially. Air embolism through
such a laceration is also a real concern.
In the absence of haemodynamic compromise, it is prudent to wait for
the results of an emergent chest X-ray prior to intervention. This will
avoid patients such as that shown below, where a right upper lobe
collapse due to endobronchial intubation resulted in hypoxia and
tracheal deviation - mimicking a tension pneumothorax on the opposite
side The patient received an unnecessary left chest tube.
Right upper lobe collapse mimics left tension
The trauma-list has extensively debated needle thoracocentesis and
discussions has been archived. The conclusion of the debate was:
Needle decompression can be associated with complications.
It should not be used lightly.
It should never be used just because we don't hear breath sounds on
one side. BUT
In clear cut cases: shock with distended neck veins, reduced breath
sounds, deviated trachea, it could be life saving.
Chest Drain Placement
Chest tube placement is the definitive treatment of traumatic
pneumothorax. In most centres, chest tubes should be immediately
available in the resuscitation room and placement is usually rapid. The
controlled placement of a chest tube is preferable to blind needle
thoracostomy. This is provided the patient's respiratory and
haemodynamic status will tolerate the extra minutes it takes to perform
the surgical thoracostomy.
Once the pleura is entered (blunt dissection), the tension is
decompressed and chest tube placement can be performed without haste.
This is especially true of the patient who is being manually ventilated
with positive pressure, and surgical thoracostomies without chest tube
placement have been described in the prehospital setting.
gastrothorax has been described and may be confused with a tension
pneumothorax. There is haemodynamic compromise, tracheal &
mediastinal deviation, and decreased air entry in the affected
hemithorax (usually left). Tension gastrothorax occurs in spontaneously
breathing patients with a large diaphragmatic tear (usually blunt
trauma). This emphasises the importance of blunt dissection and
examining the pleural space with a finger prior to chest tube insertion.
Bilateral tension pneumothoraces
Cullinane DC, Morris JA Jr, Bass JG, Rutherford EJ.
Needlethoracostomy may not be indicated in the trauma patient. Injury.
Eckstein M . Suyehara D. Needle thoracostomy in the prehospital
setting. Prehospital Emergency Care. 2(2):132-5, 1998
Britten S; Palmer SH; Snow TM. Needle thoracocentesis in tension
pneumothorax: insufficient cannula length and potential failure.
Tadler SC, Burton JH. Intrathoracic stomach presenting as acute
tension gastrothorax. Am J Emerg Med 1999;17:370-1
Here's the scenario: You
and your partner are out in the woods going to relieve your
teammates doing surveillance on a suspected meth lab. You and he
push a branch aside unknowingly upsetting a hornets nest. Both of
you get stung at least two or three times as you're trying to get
out of the area and somewhere where you're not getting chased and
stung. As soon as it seems clear, you stop and notice your partner,
eyes wide in fear, grabbing his throat and moving his mouth but only
a high-pitched, squeaking sound is coming out and you notice his
lips are swollen and turning blue. As you move to him while asking
if he's okay, his eyes roll back into his head and he collapses at
your feet. Would
know what to do?
Tac Med Tip of the Week #10---10 Feb 2012
by Dark Angel Medical, LLC on Friday, 10 February 2012 at 16:40 ·
Many of us know someone who is highly allergic to certain substances,
whether it is venom, certain foods or medications. The question is; Would
we know what to do if we witnessed an anaphylactic reaction?
What is an anaphylactic reaction? (also, anaphylaxis)
It is a severe, rapid-acting,
life-threatening event in which an immune response has been triggered by
some substance and the resultant histamine
release brings about rapid inflammation of the soft tissues in the upper
airway which can cause a partial to complete airway obstruction leading to
respiratory arrest which leads, unless treated, to cardiac arrest and
death. It is said to affect up to 2% of the population worldwide on a
yearly basis with up to 500 deaths reported yearly in the U.S.
Now that you know what it is, how do you
What are the signs and symptoms?
are what you see and symptoms
are what the victim tells you they're feeling. They may say they're having a
breathing or that they're itchy
or even nauseated,hot or faint-feeling.
You may hear a high-pitched
sound coming out of their mouth. This is called stridor
and is a sign of upper airway swelling and the air rushing through the
narrowed opening is much like when we purse our lips and whistle. Another
sound is wheezing
which is coming from the airway narrowing and also can be caused by fluid
leakage into the pulmonary tissue. You may see noticeable
around the eyes or lips and they may break
out in hives (see also urticaria).
Any of this is a definite, life-threatening
emergency and must be addressed immediately.
How do you treat it?
First...monitor their airway,
breathing, circulation and call 911. If a person has known allergy,
then hopefully they are carrying an Epi-Pen
(more info click,
video on how to use click).
(also called commonly adrenaline) is the best known first-line defense in
the treatment of anaphylaxis and is as easy to obtain as seeing your doctor
and getting a prescription written if you have known allergies. It has no
known contraindications though it should be used with caution in those with
known cardiac conditions but remember, Airway,
Airway, Airway! If the person has lost consciousness, check for a
medical alert bracelet or anything else that may identify their allergy and
see if they have an Epi-Pen on their person. If you're unsure of how to use
it, the auto-injector has instructions and pictures printed on the side in
The Epi-Pen needs to be administered at the first signs of anaphylaxis and
is simple and effective but is by no means a substitute for advanced care in
the ER. The Epi-Pen comes in a protective case and needs to be removed and
the blue safety cap taken out while holding the injector in your hand
with the orange tip (needle) down. Ensure you wrap your hand around the
injector as you would a water bottle as the injector is now 'armed'. Press
the orange tip against your outer thigh muscle until you hear a 'click'.
This 'click' is the spring releasing the needle and pushing it into your
thigh and injecting the epinephrine. Hold the injector agains your thigh for
at least 10 seconds and then remove it from your thigh. The orange cap will
cover the needle protecting you and others from a 'stick'. At this point, if
it has not already been done, call 911 and get EMS activated. Ensure
used auto-injector goes with you or the victim to the hospital.
The best course of action in anaphylaxis is prevention. Try to stay away
from substances you know you're allergic to. Unfortunately, though, life
isn't that easy and Mr. Murphy likes to mess with us. In that case, carry an
Epi-Pen (or two) with you and make sure to tell those around you what you're
allergic to and let them know where your injectors are. The life you save
may very well be your own!
It's quick and easy. Recognize it and Treat
it. Blue top off, orange tip into thigh for 10 seconds and call 911.
You and your team make entry into the room, immediately make contact
to the front and as you're moving in, you notice your teammate's
head snap back and see him go limp on the deck. You move past him
and assist the team in neutralizing the threat and clearing the
room. Your priorities then shift from "Mission Accomplishment" to
"Self-Aid and Buddy Care". You move back to your team mate and
notice a hole right under his right cheek and a crease on the right
side of his head right above his ear with a large amount of bleeding
coming from his nose, mouth and ear. You grab his shoulder strap and
drag him outside behind an automobile. As you glove up, you're
talking to him but he only moans and gurgles in reply. What
do you do?
Tac Med Tip of the Week #12---2 March 2012
by Dark Angel Medical, LLC on Saturday, 3 March 2012 at 12:24 ·
Gunshot wounds to the head have an extremely high mortality rate, exceeding
90% and out of all the traumatic head injuries, GSW's to the head have a
less than 10% survival rate. This is due to your body's nerve center being
contained in the cranial vault of the skull. Once that has interrupted,
survivability is markedly decreased.
Let's take a look at the victim in our scenario. What's the first thing we
need to do? As we are dragging him to cover to continue treatment we
talking to him and assessing his level of consciousness. Always
get a baseline neuro assessment on any casualty. Look for and control any
life-threatening hemorrhage. In this case, he won't bleed to death
so we move on.
Airway is going to be a huge
concern for us for a couple of reasons.
The facial region is extremely vascular and will bleed a lot
in addition to the large amount of bones, teeth and soft tissue
which can lead to an airway obstruction.
A head injury casualty may not be conscious enough to protect
their own airway so it's up to us to ensure it's patency.
Place the casualty
on their side in the recovery position to allow gravity to assist with the
drainage of blood or other fluid away from the airway and help
keep the tongue from occluding the airway as well.
are not a candidate for an NPA due to the facial trauma.
If in a vehicle or
in a seated position, you can also lean the victim forward. This
will also keep their head up and decrease intracranial pressure.
This victim will need an advanced airway with high concentration oxygen to
ensure a patent airway adequate oxygenation of the brain is maintained.
Do the best you can to prevent them from aspirating
blood or vomit as aspiration of these substances can lead to a chemical
which has a 50% mortality rate. In
this scenario, airway is king.
and feel for the breathing of the victim. Is it a regular
pattern? Is it labored? Is it noisy?
Get the bleeding
under control as best you can with the use of direct pressure and
with superficial bleeding, hemostatic gauze and direct pressure/pressure
Check their neuro
status again (and very frequently).
Talk to them to gauge their orientation and their response to
Look at their pupils and shine a light into them.
Do the pupils react to the light by contracting?
Are they fixed and dilated? Is one large and one small?
If they are reacting quickly, this is a good sign as it shows
the brain is being perfused well by blood and oxygen. (two of
it's favorite things next to glucose)
If they are sluggish, it can indicate decreased perfusion
caused by swelling or lack of volume, which can lead to bigger
problems (ie. build up of waste products, leading to high
concentration of CO2 which leads to swelling and eventually
the brain herniating out of the foramen
magnum--the large hole in the base of the skull
which the brain stem goes out of--this is fatal)
If the pupils are fixed and dilated and non-reactive to light,
this is an ominous sign.
If one pupil is larger than the other, this can indicate
injury an the opposite side of the head. (remember, the optic
nerves cross from opposite sides of the brain). (optic
chiasm in front ot the pituitary gland)
Expose the victim
for any further injuries and treat as necessary.
Keep their head
elevated, protect the airway and keep them warm.
Watch for any
signs and symptoms of shock and evacuate to a higher level of care
A head injury is a game-changer. Even if you do everything in your power
correctly, the outcome may not be in their favor. We can only treat what we
can see and to the level of our training. The rest is out of our hands. At
the end of the day, knowing that you put 110% of your effort into helping
another person is what it's all about.
Talk to them and
assess their neuro function, control life-threatening hemorrhage, maintain
airway, monitor breathing, treat other circulatory injuries, reassess
neuro, expose, watch for shock, reassess, evacuate.
Until next week, stay safe.
Simplicity Under Stress
Note: The victim of a gunshot wound my have seizures (click).
lasting for longer than minutes can cause further brain injury. Fast
medevac is essential!
Combat Medic's Prayer by Dark Angel Medical, LLC on
Friday, 9 December 2011 at 15:48 ·
I ask for your divine strength
to meet the demands of my profession.
Help me to be the finest medic,
both technically and tactically.
If I am called to the battlefield,
give me the courage to preserve the lives of our fighting forces
by providing medical care to all who are in need.
If, while on the battlefield, I am called upon to
defend myself or the fallen I am caring for,
I pray, have St. Michael guide my hands, steady my aim
and make my rounds fly true,
so that I may live to continue my mission and lend aid to those in
If I am called to a mission of peace,
give me the strength to lead by caring
for those who need my assistance.
help me to take care of my own
spiritual, physical, and emotional needs.
Help me don my spiritual armor and
stay strong in my faith
Teach me to trust
in your presence and never-failing love.
When we hear them call for us, we run to
When we hear the gunfire and cries of the wounded, we run to them.
When we hear the crack of bullets over our heads, we run to them.
Even if it's to hold their hands and look into their eyes as they draw
their last breath and they know they have died well, not in vain and not
alone; we run to them.
We will run to them. We will defend them. We will care for and comfort
them. We will not leave them behind.
It's not our job. It's our calling.
Remember folks....the best tactical medicine is overwhelming
suppressive fire! Lay it down hard and fast and get off the X!!!
Magazines go in mag pouches and IFAK's go in Med Pouches. Confusion in
a life-threatening situation could be less than ideal. The D.A.R.K. has
a dedicated-use pouch made specifically for the D.A.R.K. insert. Keep it
simple. Keep it safe. Simplicity Under Stress.
What are the signs and symptoms of a Flail Chest?
(back to article)
Diagrams depicting the paradoxical motion observed during respiration with a
The characteristic paradoxical motion of the flail segment occurs due to
pressure changes associated with respiration that the rib cage normally
During normal inspiration, the diaphragm contracts and intercostal
muscles push the rib cage out. Pressure in the thorax decreases below
atmospheric pressure, and air rushes in through the trachea. However, a
flail segment will not resist the decreased pressure and will appear to
push in while the rest of the rib cage expands.
During normal expiration, the diaphragm and intercostal muscles relax,
allowing the abdominal organs to push air upwards and out of the thorax.
However, a flail segment will also be pushed out while the rest of the
rib cage contracts.
The constant motion of the ribs in the flail segment at the site of the
fracture is extremely painful, and, untreated, the sharp broken edges of the
ribs are likely to eventually puncture the pleural sac and lung, possibly
causing a pneumothorax. The concern about "mediastinal flutter" (the shift
of the mediastinum with paradoxical diaphragm movement) does not appear to
What is a Beaten Zone?
(back to article) Here's it is used in a humorous
slang sense as "where the bullets are impacting." It is a military
term which is used to describe a target area usually with the bullets
from a machine gun impacting an area from an arcing ballistic
of Fire and elliptical beaten
photograph of beaten zone created by multiple machine guns
The Beaten Zone is a concept in indirect infantry small arms fire,
specifically machine guns. It describes the area between the "first catch"
and the "last graze" of a bullet's trajectory. At the first of these
points, a bullet will hit a standing man in the head, at the last of these
points, as the bullet drops, it will hit a standing man in the feet.
Anyone standing within the beaten zone will be hit somewhere from head to
The concept works best as part of a static defence with the area covered
by a position plotted out beforehand. Usually the machine guns will be
mounted on a tripod and indirect fire sights (such as a dial sight) fitted
in addition to, or instead of, direct fire ones. Fire can then be called
in by spotters to engage specific points in the guns' field of fire, even
if out of sight of the machine gunners.
Overlapping machine guns, creating a crossfire, using the beaten zone
concept, together with the idea of enfilading were an important part of
World War I.
Histamine is the chemical (neuro-transmitter) your
body produces when you're having an allergic reaction. Although there is
always some histamine in your body, a mosquito bite (for example), causes
your body to release more histamine in the area of the bite, making your
skin red and itchy. In extreme cases, histamine levels in someone who is
allergic to a bee sting or a particular food like strawberries can be
elevated so high that it causes anaphylactic shock and possibly death.
Adrenaline (Epinephrine) is the only chemical that can quickly eliminate
histamine in a person. So called "antihistamines" like Benadryl only work
to block some of your body's histamine receptors (relieving some histamine
related symptoms), they do not remove histamine. If you do go into
anaphylactic shock (where your organs essentially shut down), it is
essential that you are injected with adrenaline immediately to counteract
the dangerously high histamine level and prevent death. My histamine level
was very high but not dangerous. My body tried in vain to reduce this high
level of histamine to a normal level, by releasing abnormally large
quantities (spikes) of adrenaline into my blood stream. This created
nervous energy and sometimes even panic attacks if the spikes were large
enough. The body normally has a certain amount of adrenaline that
increases and decreases slightly to balance your body's histamine level.
In its attempt to reduce my histamine level, my body would essentially use
up all my adrenaline (as shown by my blood test). This would leave me
feeling anywhere from moderately tired to frighteningly exhausted. Its
probably difficult to imagine being so drained of energy that it would
actually scare you, but it happened to me frequently. My high histamine
level also caused my Meniere's like symptoms, as well as difficulty
thinking, focusing, and remembering things. Its possible that many people
diagnosed with Meniere's Disease actually have a high histamine level and
not an inner ear problem.
High histamine levels can be gradually reduced over time if the cause of
the "allergic" (autoimmune) reaction can be found. In my case it was
determined that I had trouble metabolizing sulfur (contained in many
foods) and had an excess of a chemical called histadine which is also
contained in many foods, especially breads. The sulfur and histadine in
the foods I ate caused my body to produce large quantities of histamine.
This isn't really an allergic reaction in the typical sense. Tomatoes,
wheat, milk and citrus fruits all contain high quantities of sulfur which
caused my body to produce large quantities of histamine. To reduce my
histamine level, I had to eliminate these foods from my diet (see
Histamine Diet). If I ate some pizza (which contains tomato (sauce), wheat
(crust), and milk (cheese) ) I would usually have a panic attack two or
three days later because it took that long for the whole sulfur,
histadine, histamine, adrenaline reaction process to take place. I would
never have associated a panic attack or dizziness attack with something I
ate two or three days before.
Dog wounded while trying to prevent a suicide bomber
from entering his friends' barracks. Survived.
CSAR working to leave no man behind.
(link to Amazon.com)
Photo Courtesy Mad
Duo Thanks guys!
This is not the proper
method for Mr. Hard 2 Kill
to clean dried mucous from his nose!
(click to enlarge)
This is a clean through and through gunshot wound from the abdomen
and out of the hip. This is a hard contact M-1 Garand 30-06
FMJ home accident. It is hard to imagine the contained
muzzle blast and powerful round not causing more damage. The
accident victim survived and is healed. The following is his
"This is the result of me
tripping over my cat onto a set of stairs while carrying a
loaded M-1 Garand and falling on top of it (kat: a hard
contact wound). It was a 30.06 FMJ round. Shot went through my
stomach and out of my hip." ~Mr Greenbean20k02
lundi 7 juin, en début d’après-midi, un premier homme du 2e REP à
terre dans une ruelle de Shaehwatay, un village en apparence
paisible qui s’est révélé être un piège. Le jeune légionnaire,
légèrement blessé, informe ses camarades que l’ennemi est tout
proche. | Photo Jonathan Alpeyrie
Monday 7 June in the start of
the afternoon the first soldier of the 2nd REP lies on the ground
in an alley in Shaehwatay, a village in appearences peaceful and
has shown itself to be a trap. The young legionnaire,
lightly wounded, told his teammates that the enemy are right next
to them. | Photo Jonathan Alpeyrie | Translation: Kathy
reporter followed an operation with the 2nd REP(Régiment
Étranger de Parachutistes: Airborne Foreign
Legion) and saw many men fall in action. Their
comrades complained to him about the Rules of Engagement
which they were saddled with.
France is at war with Afghanistan, and the Legion,
for the first time is in the front line as the first in
battle. Since recent months, the 2nd and 3rd
companies of the 2nd REP have been with Allied forces in
engagement to take back the valley of
Tagab* in the east of the country. A tense zone
because of the "insurgents," the official term for
designating the Talibans and the population who are
close to them. Loyal to their reputation as elite
warriors, the Legionnaires were positioned in front of
the COP (Combat Outpost possibly COP 51, a French manned
medical facility) as far as the 50th parallel.
*Kat's note: Tagab valley approx 60km east of Kabul at
the foot of the Hindu Kush is very bad insurgent country.
Just got off the horn with Kerry Davis
from Dark Angel Medical, LLC.
Kerry is a great guy with what seems to be a great product!
For those of you who are not familiar,
Dark Angel Medical currently produces the Dark Action Response Kit or D.A.R.K.
The kit is not only endorsed by Chris
Costa, but is also approved
and used by many active
If you would like to know more about Dark
Angel Medical, you can visit their site by clicking
on the attached link. Also, check back to FrontSitePost.com
later tomorrow to read an exclusive article on Dark Angel Medical.
Kerry Davis is the founder and owner
of the fast-growing combat medical supply company Dark Angel Medical. To
know more about Dark Angel Medical, we believe you need to know more about
Kerry, started his military career as field medic in the US Air Force. He
was given special duty assignment to go to and train at Pope AFB/Ft. Bragg
where he not only went through jump school, but learned much of what he does
now from the small units he worked with. With Kerry’s growing love for
competitive shooting, he soon was able to combine the two things he loved
most: shooting and medicine. Kerry became an instructor at Officer Training
School, teaching courses like Medical Readiness Indoctrination. He also
taught CPR, PALS, ACLS and Self-Aid/Buddy Care, as well as assisting the
local paramedic school with pharmacology and cardiology instruction as an
adjunct. Kerry did all of this while also working as a civilian paramedic
and taking classes towards his nursing degree. As his active duty career
came to an end, Kerry joined the reserves, where he had more time to study
and complete his degree.
After military life, Kerry worked for a number of well-known companies in
the industry. While working as a RN in the ER and ICU, Kerry ran into many
instances where the knowledge of basic life saving skills would have saved
lives. For this reason, he started working on a curriculum for a medical
class. Without a platform to launch from, he brought the concept to Magpul
Dynamics, who referred him to Chris Costa. He proceeded to take a couple of
classes with Costa, and then began to teach an impromptu GSW class. Kerry
worked with Magpul for a time as the Director of Medical Training, and was
picked up by the Sig Sauer Academy. It is with SIG that he has been on the
road teaching “Bullets and Bandages”, as well as other classes with them
since this past fall.
“Our goal is to put out a good product for the good guys. If I teach 50,000
people and only 1 of them use the kit or info to save a life, then it is
100% worth it. Folks just don’t realize that just because the gunfight is
over, the fight for your life might just be starting and that’s where having
the proper training, mindset and a simple, yet effective, kit come into
If Kerry’s credentials alone don’t speak for themselves about what Dark
Angel Medical has set out to do, then perhaps you should look at the company
and their product.
D.A.R.K. (Direct Action Response Kit)
The adopted motto of Dark Angel Medical seems pretty self explanatory:
“Simplicity Under Stress“. Their sole product the D.A.R.K. (Direct Action
Response Kit) is currently in use by many active duty military personnel and
also industry professionals. The kit is currently endorsed by Chris Costa of
Costa Ludus and can be purchased on his site, www.costaludus.com. The kit
promises to include everything you need and nothing you don’t. Although
simplicity is the key word when describing the kit, it still looks robust
enough to handle many important medical tasks.
Clearly a compact kit
For more basic information, including the kits contents you can visit Dark
Angel Medial’s site by clicking here.
Front Site Post has been given the privilege to give one of the first
professional product reviews of the D.A.R.K., and this review should be
posted later next week. Stay tuned to FSP as we continue to bring you the
very best in product reviews.
If you have an original product you would like us to review or if you have a
review request please visit the “Contact
Us” page on DarkAngelMedical.com
GET OFF THE X part 2
medic rules. On my first day in Vietnam, a sergeant took me aside and
said, “Forget what you learned in medic school. I am going to tell you
what you need to survive over here. The first rule is
never to go into a zeroed-in position.” The
corollary to this obviously is to get out of the zeroed-In position
and to get your casualty out also.If
somebody just got shot by a sniper, and you go over there and try to
grab him and drag him to cover, you are going to get shot by the
sniper, too. If the casualty is conscious, get him to crawl to cover.
How to keep going?
Then there is this issue of non-survivable injuries such as the
Ranger with half of the body blown away, but still talking. Put
yourself in the place of a 20-year-old who is watching someone die
while he is talking to him. How do you handle this and how do you
prioritize the management of that individual versus the care of the
5. Rule two is: ‘Always disarm the patient
if there is any doubt about his ability to use his weapon effectively.”Disarm patients
who are in shock, who are hypoxic, who have a head injury, or who have
just gotten morphine. If someone has been shot in the leg and has a
tourniquet on it and the bleeding is controlled, then he can still be an
asset to his unit and help to return fire or operate a radio.
6. Attempting to resuscitate a patient in cardiac arrest from blunt trauma
is futile even in the best of circumstances. Do
not even think about doing CPR. This may be difficult to face,
since this is your buddy that you were talking to 2 minutes ago. That
is the worst thing about combat. You cannot train for that. You can train
to keep going in the face of adversity, but you cannot train to see your
buddies get hurt or killed.
7. Everyone in the military should learn
first aid to be able to care for their buddy or themselves, since the
medic may be the first one to get shot. When I was a medic, they
used to give us little aid bags to carry around. It
did not take long for the Vietcong to figure out who the medic was.
Put the medical equipment in something that is not so conspicuous.
8. People who have traumatic amputations
from explosions, mines, or booby traps often have bleeding. However, as a
result of retraction and contraction of blood vessels, the bleeding is
usually minimal and endorphins kick in. I have had casualties with one or
both feet blown off who did not even realize they were injured. They kept
trying to walk and could not understand why they could not. In the heat of
battle, a casualty may not even realize he has been shot.
9. There are lots of ways to move people, including on a poncho, on a poncho
liner, or by grabbing them by their web gear, but
these techniques need to be practiced.
10. It is very difficult to carry
casualties over rough terrain. You need six people to carry someone any
distance and they wear down fairly rapidly, which then reduces
their ability to fight. So, if you can get any form of mechanized transport,
First of all let me say that Kerry Davis is highly regarded in the training
industry. His words on the matter of training are spot on. It doesn’t make
much sense to train to shoot someone and fight your way out of a situation
and then not train in basic medical skills under the same conditions. This
is not Golf or Tennis, this is self defense, which is to say this FIGHTING!
Someone WILL get hurt. Understand, that if something happens in the real
world that involves you pulling out your gun it will almost undoubtedly be
fast, dynamic, up close, violent, and chaotic. We can’t control those
bullets once they leave the barrel and we certainly can’t control what the
threat shoots at! Everyone should be prepared to save life in the event of a
real world life and death event. It’s crazy to think that while being
involved in this community and being involved in shooting sports and
training, that people don’t prioritize tactical medicine or basic first aid
I would say less than 50 % of people in my unit carry an
IFAK. Its never in the same place ( i’ve seen it worn behind the shoulder by
an NCO) or properly packed. The CSM put out a email stating where every
pouch on your kit has to go. I had to take off pouches I use for medical
supplies for TCCC and replace them with grenade pouches… idk any line medics
carrying grenades right now. But of course when this ****** shows up for his
“every one did a great job in the field speech” He’s decked like an airsoft
kid. Do your medic a favor! Create an sop to put your IFAK or w/e pouch you
buy in the same place preferably on a side so we can access it if your prone
or supine. The Blue CATs you stole from the medic supply room are for
training dont put that thing in your IFAK. Also I’ve never seen one but I
would love a internal framed ruck that has a center compartment that unzips
like my LBT aid bag but has storage below for my personal gear and side
compartment that do the same thing, and the top pouch on top of the center
compartment should be a cls bag that can be ripped off. It should be
designed to be worn with issued armor, have ammo pouches like that little
ares bag, it would be great it was shaped like something natural and not a
rectangle, have a hydration pocket you can access with out taking anything
out of the ruck, keep the velcro to a minimum, be available with out the
internal pockets for the aid bag ( cuz i’ve already been issued alot of
them) and not cost a 1000 dollars. who ever comes up with that bag is the
man, kirafu would probably make the best one.
SY March 7, 2012 at 1:02 am
What gets me is the training the Red Cross provides when
it comes ot any kind of trauma. They teach that you should only put a
tourniquet on as a last resort. I was going through said training as a
requirement for a personal security gig I had a few years ago. I raised my
hand and said that the person is more likely to survive if you just throw
one on at the start especially if the person is bleeding pretty good since
you have no idea what kind of internal injury the individual may have. The
reply was “If you do that the person will lose their limb.” From here it
went downhill quick. I asked if they would rather be missing their leg or be
dead with both legs attached and well she didn;t like that too much. Also
threw in the fact that you have ot leave a tourniquet on for a while before
you have to worry about losing the limb and that you can get an individual
to an ER well within that time. Then I threw out the whole. Mam have you
ever been in a trauma situation or do you just teach it. Don’t worry I still
B March 7, 2012 at 2:53 am
Huge difference between Red Cross first aid training and
TCCC. Unfortunately, “Tourniquet as a last resort” is still the standard of
care on the civilian side, although this is really starting to change. The
next time a first aid instructor tells you that the pt will lose their limb
if you apply a tourniquet, ask them how orthopedic surgeons can apply them
while they are replacing knee joints for six hours. The last time I went
through a contractor training program, the company actually brought in one
of their medics who gave a very good TCCC overview.
L. March 7, 2012
Much depends on the TQ itself and how it’s applied. An extension cord might
due for a time in extremis but the neurological outcome probably wont be
good. A TQ of a minimum width i.e. 1.5″ – 2″ should help alleviate many
DF March 7, 2012 at 8:36 pm
NCTI Has good programs around he country. They even have
a 3 week accelerated EMT-B class. Thats who i went through when i was a
civilian. I did the 8 week course, it was pretty intense. Then i went
through the 18 Delta course, and my mind was BLOWN!
BR. March 6, 2012 at 4:34 pm
As a veteran, and in the Infantry, we took our medical
training VERY seriously. I got out just as the IFAK started to become
issue-but, I always carried some sort of trauma kit with me. Our company
encouraged every single soldier, from lowly private up to the PSG to be at
LEAST combat lifesaver certified, so most of us carried that kit around. We
did refresher training every 6 months, but we did hip pocket training for
wounds damn near all the time. When we were doing field training, we ALWAYS
practiced the first aid part on wounded. Train like you fight….