by Kerry Davis (Pocket Doc) of
Dark Angel Medical, LLC
  and Dark Angel on Facebook


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 helping folks.

I've also been teaching folks how to help themselves and others.

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 forget that.

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 remember those?)

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 questions.

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.
Stay safe,
Pocket Doc

Please have patience with me as I play with the design to facilitate its ease of understanding and use.


                    ~ Kathy S.

Tactical Medicine:  Techniques, Tips and Procedures
(TTP with Wings)
  • FAQs
  • Links of interest
  • Quick test of your tacmed knowledge

Webpage text highlighting notes: 

Pocket Doc teaching a class
2nd Generation DARK kit (click for details)

The Older Dark Kit
Quick Test
See if you know what to do if you saw this range accident

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 and civilian healthcare 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 what we’re all about.




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, you grab 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.

What do you do?



Hey 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 breathing.”

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.

click 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 health issues.

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 pressure.

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.

Just remember, “Stop the Bleeding, Start the Breathing.”

HINTS:  Okay guys, here's the deal. There are lots of large vessels in the lower leg.

  1. You don't have to dissect an artery to bleed out.
  2. Direct 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 pain.
  3. If 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.
    1. TQ times are also increasing to <4 hrs.
      1. A 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 solid.
Our main goal is stopping the bleeding by any means necessary as quickly as possible.
Primum Non Nocere -- First Do No Harm


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

“Daily Life”

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 aforementioned subjects.

But, isn’t 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 self-reliant.

“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


*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 casualties.

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 eyes 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 around 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 ‘mama.’

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 everything correctly.

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 position.

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.

You’ve just completed triage and treatment of multiple motor-vehicle accident victims to the best of your ability.

Remember, triage 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.

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 limited 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 help.

Triage is not about selecting who lives and who dies but 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.


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 obvious injuries.

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 position.

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?
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.
  1. Get the proper training to utilize your firearm.
  2. Make a plan with your family.
  3. Get the proper training to utilize a personal trauma kit.
  4. 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
Kat's notes: 
  • 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 or not

  • 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 family members)
    • 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 kit, the 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 taken down.
  • 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 things
      • 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.
      • How ever accurate you are on a static range, you will be at best half as accurate when you and your attacker is moving, even if you aren't panic-stricken!
      • 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.


not finished editing

Tac Med Tip of the Week #15---30 March 2012

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 D.A.R.K.
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 that luxury.

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 windlass.

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 of shock.

Airway? 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.”

C-Spine precautions? You can roll up cardboard and tape it to either side of the head. Same with towels, blankets, shoes, boots, etc. The goal 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.

Breathing? 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 big 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 MacGyver on!

Keep if safe. Keep it simple.
Until next week, stay safe.

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 immediate pain.

If the bone ends rub together you may hear or feel a ‘crunching’ sound called “crepitus”. (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).

Bones, especially 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.

Check 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 circulation.

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 injuries.

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 femur fx look for 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 anatomical splint.

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.

Continue to monitor the victim’s LOC (level of consciousness) and observe for s/sx of shock and get to a definitive care facility as quickly as possible.

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” course.

Until next week, stay safe.


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

GET OFF THE "X"!!!    This is a term that many of us are familiar with.

We're going to talk a little bit about proper care under fire and casualty evacuation so 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 be repeated)

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.

Once off of the X and behind cover, we must evaluate and treat any injuries sustained.

If contact has been made and injuries have been sustained:

Counter that contact with suppressive fire. This will allow the casualty, if able to move, to move quickly and laterally out of the cone of fire and behind cover where they can render self-aid.

Note:  Although many of you will know the difference between Cover and Concealment, there are many who will not or have not yet received tactical/defensive training.
  • Cover provides protection from bullets, shrapnel, flying debris.
  • Concealment is something which will hide you but will not stop bullets or any other ballistic 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 combat ineffective.

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.

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?

You must maintain the warrior mindset that you will prevail and that the mission will be accomplished.

Just because 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 cover 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.
"...My 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.

Tourniquet Function and Application

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(please click on this photo of the CST/FET soldier for a cropped closeup of her loadout)

Pocket Doc's 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.

Massive, life-threatening hemorrhage accounts for approximately 80% of all combat deaths with about 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 shock and that the blood 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 studies.

  • Put the TQ on like a military haircut; high and tight.
  • Reassess your casualty every 5 minutes.
    • check for shock
    • ensure there is no bleeding
  • Know your equipment. Practice with your equipment.

Simplicity Under Stress.

How fast should I be applying a Tourniquet?

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You want to get it on, tightened enough to stop ALL arterial flow and secured in an ideal situation in less than 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 Dry-Fire Practice".

Remember, Not the least Oozing of blood Allowed!!


An important good habit;
Carry Two Tourniquets (TQ)

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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 it 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.

Tip:  Learn where the important vascular/arterial pressure points are! CLICK

The D.A.R.K. Pressure Bandage (Israeli Bandage)

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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 aid 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.

The Emergency Bandage is a pretty versatile piece of kit in 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 enough 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 TQ or 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 pressure/compression.

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!

Until next week, stay safe.
Simplicity Under Stress. 

Wound Packing

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Dark Angel Medical, LLC

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:

1) 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, some 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".

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 hand into your dominant hand and push the gauze into the wound channel/cavity with your index finger.

Again, the goal is to get even pressure throughout the wound.

Remember, these 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 different velocities.

Blast injuries may have varying levels of tissue injury and multiple wound channels 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.

Hold 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 shock.

Note: We have purposely not talked about various packing materials or pressure dressings as this will be discussed in future installments.

Helpful hint:  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.

Just remember:

Treat a wound like your rucksack: Pack it full and wrap it tight.

Until next week, stay safe.
Simplicity Under Stress.


Open, Stabalize and Maintain a Patient Airway
(when not to use)
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Dark Angel Medical, LLC

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 patent airway.

After, massive, 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 hemorrhage.

i.e. Check breathing and airway!

There are a couple of elements which can come into play here such as do they 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 pressing priority.

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.

  Opening airway

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 risk.

Example 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 the nostril.

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 airway.

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.

What is Hemorraghic Shock?
(click for Treatment of Hemorraghic Shock)

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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 hemorrhagic shock. 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:   When 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 body.

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 II of 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 organs.

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 times.

In Stage III, the victim has lost up to 2000ml (that’s 2 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 consciousness.

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”.

How Do We Treat Hemorragic Shock?

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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).

Second, volume 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.

Third.  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 Position)

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.

Summary/Memory Aid
Bleeding stopped, keep ‘em warm, legs up.

Until next week, stay safe.
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 ·

Traumatic Amputation
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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 hours!

Get a new cooler. ;-)

Until next week, stay safe.

Simplicity Under Stress

Cold Weather, Cold Environment considerations

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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.

Note:  Wool 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.

Combine the insensible loss, decreased intake of fluids by mouth and increased urination and you're heading down a hard road in a hurry.

Wounds plus cold weather

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 tissue further.

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 touch.

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 them rapidly.

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 lightweight.

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

Fit to Fight

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(click for "Airborne:  Rock Solid" Jody call)
Tac Med Tip of the Week #9--3 Feb 2012
by Dark Angel Medical, LLC on Friday, 3 February 2012 at 20:22 ·

(click for Jody Calls, lyrics)

This week's Tac Med Tip of the Week: Fit To Fight

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 and rescuee.

An often overlooked component in the training environment is overall physical fitness.

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 hydrated.

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 simply overtrain".

That overtraining can lead to more injuries rather than preventing them.
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:  While 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 week. 

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 result!

This is just a framework. Build on it, customize it and make it yours.   Remember:
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 Under Stress

The Sucking Chest Wound (Pneumothorax)

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Tac Med Tip of the Week time....

Today we'll talk about a condition typically known as a "sucking chest wound".

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 the lung.

What are the symptoms?

What needs to be done?
This is 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.
  1. Control any life threatening hemorrhage,
  2. evaluate the airway,
  3. have the casualty exhale,
  4. apply 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 teach 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 field, we 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,
The victim's 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:
  •     Deviation of the trachea away from the side of the tension
  • Shift of the mediastinum.
  • Depression of the hemi-diaphragm.

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 injuries.

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.
Until next week, stay safe.

VIDEOS illustrating the Sucking Chest Wound:

Video:  What a sucking chest wound can look like:

From movie "Three Kings," Warner Brothers, released Oct 1, 1999 and one of the best animated descriptions of a chest bullet wound pneumothorax

Simplicity Under Stress

Supplementary notes on Tension 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 room.

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 a tension:


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 mediastinal shift
Upper thorax showing position of chest tubes Right tension pneumothorax

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 lung.

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


Needle Thoracostomy

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:

  1. Needle decompression can be associated with complications.
  2. It should not be used lightly.
  3. It should never be used just because we don't hear breath sounds on one side. BUT
  4. 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.


Tension 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


Needle Thoracostomy

Tension Gastrothorax

Anaphylactic (Allergic) Shock

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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 you 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 recognize it?

What are the signs and symptoms?  Remember, signs are what you see and symptoms are what the victim tells you they're feeling. They may say they're having a hard time breathing or that they're itchy or even nauseated, hot or faint-feeling. You may hear a high-pitched whistling-type 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 swelling 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). Epinephrine (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 three steps.

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 the 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.

Until next week, stay safe.

Simplicity Under Stress

Gunshot Head Wounds

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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?

One who survived, an old wound

Why it is important to try:  click Phineas Gage

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 are 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.

        -> They 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 pneumonia which has a 50% mortality rate. In this scenario, airway is king.

Look, listen 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 bandages.

Check their neuro status again (and very frequently).

  • Talk to them to gauge their orientation and their response to stimuli.
  • 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 immediately.

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).  Seizures lasting for longer than minutes can cause further brain injury.  Fast medevac is essential!

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The Combat Medic's Prayer
by Dark Angel Medical, LLC on Friday, 9 December 2011 at 15:48 ·

Oh, Lord

 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 need.

If I am called to a mission of peace,

 give me the strength to lead by caring

 for those who need my assistance.

Finally Lord,

 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 them.
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.

More Rules for Lifesavers and Gunfighters

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What are the signs and symptoms of a Flail Chest?

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Diagrams depicting the paradoxical motion observed during respiration with a flail segment

The characteristic paradoxical motion of the flail segment occurs due to pressure changes associated with respiration that the rib cage normally resists:

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 be merited

What is a Beaten Zone?

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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 trajectory.
                                                               Cone of Fire and elliptical beaten zone             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 foot.

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.


(back to article)

    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.

More information and Chemistry of Histamine



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(images with blue borders; full sized click)

Images from the Battle of Ia Drang (click for Wikipedia)

detail (click)

Dog wounded while trying to prevent a suicide bomber
from entering his friends' barracks.  Survived.

CSAR working to leave no man behind.

detail (click)

(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 description: 

"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
Entrance of 30-06 bullet 9 o'clock to navel
(click to enlarge either image)
Exit wound on hip (possibly just above the pelvic crest)
note the silhouette of the FMJ bullet.



* translation: <just practicing my French (kat)
Le 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

Our 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.


Dark Angel Medical review from FrontSitePost

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 military personnel.

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 Davis.

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 play.”
-Kerry Davis

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.

The D.A.R.K.


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

4. Combat 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 other casualties

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, use it.


from SOFREP.com

FormerSFMedic March 20, 2012 at 4:14 pm

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 skills.

Read more: http://kitup.military.com/2012/03/missing-link-medical-training.html#ixzz1piRw2KoV
Kit Up!

TTP posts

Z March 6, 2012 at 5:28 pm, KitUp

    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 passed.

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 problems.

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….