Situational Awareness and Selecting a Treatment Position

It is essential for a medic to constantly update his situational awareness. The tactical environment is constantly changing and threat levels fluctuate every second. While providing treatment to a casualty is important, never let it overshadow the tactical situation around you. Unless you are in a secure area you must constantly reevaluate threat levels and balance the level of care provided with the current threat.

Selecting a proper position in the CCP or positioning yourself during hasty treatment is an essential part of this task. You should position your casualties in a manner that allows you to make quick visual assessments of potential threat areas or at least provide a visual on your security element (if you have one). Placing a casualty in a corner or along a wall forces the medic into the center of the room. Not only does it limit access to the patient, it puts the medic in an exposed position and makes it difficult for them to evaluate their surroundings. It also increases the occurrence of tunnel vision. It’s easy to lose focus when you can only see one thing. If possible, position casualties in the center of a room, just remember you want to minimize their exposure to open doors and windows just as you want to minimize your own. If the room is large, consider placing them near the walls; however, leave enough space between the casualty and the wall to allow yourself workspace and room to maneuver quickly if necessary.

A dead medic doesn’t save lives. Failure to understand what is occurring around you increases your risk of injury or death. In the demo-video, take note of the manner in which the medic positions himself in the room and how he is constantly checking his threat-areas while providing aid.

Take-away Points:
1. Maintaining situational awareness is as important as treating your casualty
2. Position yourself and your casualty so as to lessen your risks
3. Performing your duties as a medic does not relieve of your tactical responsibilities

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

To Pack or Not to Pack: That is the Question

Hemorrhage control is one of the most important aspects of tactical medicine. As studies suggest, exsanguination from extremity wounds is the leading cause of death on the battlefield. Therefore, effective hemorrhage control is of upmost importance in the field. With this in mind, we must assess the most effective way to control hemorrhage.

As most of our readers know, in the Care Under Fire (CUF) phase of treatment, a tourniquet should be the first tool used for catastrophic-hemorrhage control. Should the care provider fail to achieve hemorrhage control using a tourniquet, or the location of the hemorrhage contradicts its use, then the use of a pressure dressing and/or a hemostatic agent is the next step in the CUF phase, if the situations allows, of course.

With that said, how does one achieve and maintain hemorrhage control with a hemostatic agent or a pressure dressing? First we will explore the use of hemostatic dressings. If the care provider were to just expose the wound and dump the hemostatic agent directly into the wound, the pressure of the bleed could wash it away, thereby negating its positive effects. To prevent this from occurring, the careprovider needs to apply pressure to the wound site, so as to ensure the hemostatic agent remains in place. The most effective way to do so is to pack gauze in the wound, on top of the hemostatic agent. Doing so will provide the requisite amount of time needed by the majority of approved hemostatic agents in the field to work. If a medic decides that the situation dictates a pressure dressing, what are some of the considerations before applying a pressure dressing? If the wound is the result of high-velocity penetrating trauma from a projectile, for instance, one must remember that the projectile has produce two cavities: the permanent and the temporary. The permanent cavity is caused by the projectile coming in direct contact with tissues. The temporary cavity is caused by the lateral energy produce as the projectile passes through the body. Consequently, while a wound may appear to be a simple entry/exit type of wound, thereby requiring that application of a simple dressing, it might be deceiving. In fact, the cavitaion produced by the projectile may have extensively damaged the tissues with which it came in contact (See Figure 1).

With that said, how does a medic achieve hemorrhage control when the wound appears manageable from the outside, yet continues to bleed within? Direct pressure on the wound site might achieve it, but not likely. Should a medic then apply a dressing that is nothing more than a wound pad attached to elastic? Maybe, but that offers little more than circumferential pressure. Inadequate circumferential pressure provided by an elastic bandage is as useless as an ineffective tourniquet, because neither are going to stop bleeding. Additionally, it fails to actually apply pressure to the damaged tissue that is bleeding within the wound tract. Essentially all one has done by applying a elastic bandage to a wound that requires a pressure dressing is applied an expensive dust cover, which might provide a false sense that one has achieved hemorrhage control. A medic must apply pin-point pressure to the wound. To do so, one needs pack the wound with gauze. The illustration below speak volumes. Medics must carefully, yet aggressively go after bleeding! Packing wounds with gauze has been the cornerstone of hemorrhage control for years in the special ops medical community. Until recently, an elastic bandage and a role of gauze has been the treatment of choice for wounds that neither require nor are accessible to other methods such as tourniquets. Unfortunately, some civilian medical directors frown upon medics packing wounds in the filed. Instead, medics are directed to apply direct pressure to wounds. As mentioned above, although direct pressure is useful sometimes, medics must get pin-point pressure on wounds. All is not lost; the tides are slowly shifting. The more medics we come in contact with the more we learn of a paradigm shift toward wound packing within the military and law enforcement medical communities. In the end, whether acting as an adjunct to a hemostatic agent in gaining hemorrhage control or stopping bleeding by exerting pin-point pressure, wound packing is a necessary step that must be considered. pack


(Figure 1)
(Reprinted From Husum H, Gilbert M, Wisborg T, Saving Lives, Saving Limbs, TWN Penang, 2000) )