Primary Weapon Placement in Close-Quarters Battle

Selecting a technique for storage of a medic’s primary weapon during treatment is a difficult task.  While there are many excellent slings on the market, none are designed to functionally keep a weapon out of a medic’s way while he or she  is treating a casualty.  Some slings such as the V-tac sling provide an easily accessible point of rapid adjustment that allows a medic to push the weapon aside.  Although such slings are the best currently available, when wearing an aid-bag it can be difficult to prevent your weapon from striking the casualty, possibly causing further injury.

How might we mitigate such a problem? One method is to place the weapon behind your knees.  This technique, as with everything, has advantages and disadvantages.  The primary disadvantage is that the weapon is no longer attached to your body by a relatively strong piece of nylon.  If there is a large explosion or an incoming mortar round there is a chance you could be separated from your primary weapon.  If your environment doesn’t force you to deal with pesky insurgents lobbing mortar rounds, this may be of absolutely no concern.  Some of the advantages of this technique are well worth the possible disadvantages.  Keeping the weapon behind your knees ensures you always know where it is.  NEVER set your weapon on the ground beside you to work on a casualty.  Many highly skilled and experienced medics have left their weapons to respond to another casualty or initiate the evacuation of wounded.  Keeping it stored behind your knees is an uncomfortable reminder of your primary focus on the battlefield, and it is highly unlikely that you will forget where it is.

Some people will argue that storing your primary weapon in this location is a bad idea because of the amount of time it takes to put the weapon into operation.  The fact is that maneuvering a slung weapon while wearing an aid bag and a Camel-bak™ is not a smooth operation.  If you are presented with a threat serious enough to warrant immediate engagement that requires a reaction time of a few seconds, you are better of answering that threat with your secondary weapon.  Drawing your pistol and accurately engaging targets is something that is practiced over and over again on the range.  Take advantage of training and use it in this situation.  If you are providing aid, you should either be in a “secure” area, cleared room, or behind a position of cover.  If you face a threat that requires immediate engagement in this environment, it will likely be at close range.  If you are proficient with your secondary weapon, it should be more than sufficient to deal with the threat.  Targets at greater distances generally allow enough reaction time to access your primary weapon.

In addition to the benefit of forcing you to maintain control of your weapon,  placing the weapon behind your knees forces you to put the weapon where it belongs when moving about the objective or from one casualty to another: in your hands.  It doesn’t take long for “combat complacency” to kick-in and this is a passive means of fending it off.  A weapon slung across your back is not the best position for engaging targets.  Getting that weapon into a position that you can accurately engage targets after you have spent so much time keeping it out of your way can be difficult.  You are better off removing the weapon when you stop to treat a casualty, then slinging the weapon in a configuration suited for engagement when it is time to move.

You will have to decide what works best for you in your environment.  The key is to religiously practice the techniques you implement.  Don’t let your first time be the time that counts!

We will post an instructional video next week in order to demonstrate the above-mentioned techniques.

Tourniquet Storage in a Tactical Environment

With the increased use of tourniquets in tactical medicine, there is an active debate concerning the best location and proper method of storing a tourniquet on an individual’s equipment.  While in the end it comes down to individual preference or unit SOP, there are some locations and methods that don’t make sense.

A tourniquet is an immediate lifesaving intervention and it should be treated similarly to a secondary firearm.  Chances are your pistol is not carried in its original box packed away so you can claim a capability.  It is positioned so the operator has access to it in seconds, under the most extreme circumstances.  The same standards for accessibility and immediate operational use should be applied to your tourniquet.  The time taken to implement this intervention should be kept to an absolute minimum.  Storing a tourniquet in its plastic wrapper can be a fatal mistake.  While it increases the service life of the product, it can create a situation in which the tourniquet cannot be accessed by the individual in need.  The same situation can be created by storing the tourniquet inside a difficult-to-open, tightly-packed zippered pouch.  While storing the tourniquet in a pouch attached to your equipment is advantageous if you are the victim of a large blast since it is far less likely to be torn from your gear, the disadvantages of this location (e.g., not being able to access it quickly) outweigh the advantages. 

The best location for a tourniquet in a tactical environment is on the armor, along the midline of the operator’s body, unwrapped and pre-rigged for application.  One technique is to secure the tourniquet with multiple rubber bands.  The tourniquet can be accessed with either hand, is secured tightly to your individual equipment and is easily removed when needed. Furthermore, storing the tourniquet exposed rather than in a case or pouch provides the oft-needed visual stimulus for a rescuer or casualty to begin the act of tourniquet application.  There is a lot to be said for having the answer staring you in the face when you look down or look at a casualty.  The stress response to seeing a friend severely injured can often cause a brief period of inaction.  Having the tourniquet readily available is one small step to combat this condition.

If your unit SOP is to carry tourniquets wrapped in plastic and stored tucked away inside of a pouch, you should seriously consider reevaluating the standard.

Phases of Tactical Medicine

The Care Under Fire Phase 

The Care Under Fire (CUF) phase of treatment requires a basic management plan.  The plan is comprised of basic steps.  Remember, it is the basics that save lives.   They are as follows:

1) Regain your situational awareness.

2) Return Fire and/or take cover.

3) Direct casualty, if applicable, to remain engaged in the fight. 

4) If patient is unable to continue to fight, direct him/her to move to cover and/or apply self-aid. 

5) Prevent patient from sustaining additional wounds (SEE 3 and 4).

6) Stop Catastrophic-Hemorrhage. (self-aid, buddy-aid, medic-aid)
    A) Use tourniquets where applicable.
    B) Hemostatic agents with pressure dressing if tactically feasible.

7) Airway mangement ought to be deferred until the Tactical Field Care phase.
                                                                                         
The above is a loose guide. Do not limit yourself to algorithmic medicine.

Next time we will examine each step more in-depth.

If you have any comments, please send them to alan@tacmedsolutions.com
 

Tourniquets and Scientific Studies

A tourniquet is a piece of  live saving equipment.  With that in mind, it is troubling to know that officers are either carrying tourniquets, or contemplating the purchasing of tourniquets, that are questionable with regard to effectiveness. What is more, they are making these decisions based on a questionable scientific study, most of which they did not completely read ( TQReport). It is not being hyperbolic to state that what it is arguing is a matter of life or death. If you question that, then please revisit the last blog entry.

One not wanting to read the entire study is understandable. It is 90 pages of dry, scientific writing. At first glance, the study is methodologically sound. It is constructed to test the effectiveness of tourniquets in an environment that simulates combat conditions. However, after one reads the study completely, there is one glaring deficiency. The study did not test which tourniquets achieved 100% occlusion. I Repeat: IT DID NOT TEST IF TOURNIQUETS ACHIEVED 100% OCCLUSION.  That should be the FIRST criterion a tourniquet must meet to continue a study.  While the ISR study (see below) tested tourniquets that could achieve 100% occlusion, the Navy study did not, so all other criteria are irrelevant.  Instead, it tested how easy it was to apply an ineffective tourniquet. As the study states:

Applications to arms were performed one-handed, but use of both hands was allowed for applications to thighs. A maximum of 5 minutes was allowed to apply the tourniquet, after which time the trial was terminated as an “application failure.” Application of the tourniquet was successful if the subject vocally declared, “Tourniquet on” — indicating that he had reached a point just before continued tightening would produce unbearable pain and had secured the device — within 5 minutes of being handed the test tourniquet. Upon such a declaration, a double event mark was recorded to mark the end of the application time period. The subject was asked to remain still throughout the remainder of the procedure.

Although the above may not seem like an issue, it is. First, applying a tourniquet until one thinks he/she has achieved hemorrhage control is not how it works. One applies a tourniquet to stop bleeding. One must continue to apply pressure until the bleeding stops. It is as simple at that. Second, using pain as indicator to cease applying pressure is not a good indicator. Doing so requires one to extrapolate the findings of a conscious, non-traumatic subject and apply them to an injured patient that has experienced enough trauma to require catastrophic-hemorrhage control.

Savvy distributors and manufacturers of different tourniquets have begun using this study to tout the effectiveness of their product. Beware. They are doing so based on the age-old assumption that consumers will not take the time to read all 90 pages. For example, they are giving potential consumers a chart that gives you a snapshot of the test that enumerates the tourniquets from best to worst. Please read the studies for yourself and make an educated decision. There are two tourniquets approved for use by the Army’s Institute for Surgical Research (ISR) (ISR Tourniquet Study). Do not let the desire to carry a tourniquet that is small–and possibly ineffective–outweigh the need to achieve hemorrhage control. Furthermore, short transport times DO NOT compensate for an ineffective tourniquet that can INCREASE bleeding. Finally, rid yourself of the disturbingly-common attitude that you will not actually need one . If that is the case, save yourself both money and weight and just don’t carry one. However, read the below post before doing so.

If you have any comments, please email them to alan@tacmedsolutions.com