During the initial phases of treatment, one should perform a wound sweep to ensure there are no injuries that have been overlooked. There are different techniques, and ones tactical situation will dictate the best approach. The video above offers a broad framework and tips, which one can adjust as needed.
Below you will find copies of the two reports addressing the Virginia Tech Shootings, and the Police and EMS response to them. The first report gives an overview of the event, followed by “Key Findings” and “Recommendations”. The second report covers the EMS response more in-depth.
Unfortunately, active-shooter scenarios are events for which one must prepare. In doing so, one should study past occurrences to garner lessons-learned, so as to implement them in your response scenarios. Doing so allows one to examine one’s protocols against real-world occurrences, which may expose flaws.
How might you have done things differently?
Post answers to the comments section.
Treating an open-chest injury is straightforward. There are, however, techniques that a medic ought to consider. As the video illustrates, identifying the wound is the most important step. Body-composition, position and wound type can complicate doing so. After locating the wound, the basics apply: perform a treatment, assess the treatment, and reassess the treatment after movement and at regular intervals.
The 9-line format for casualty evacuations is a standard format. Due to the uniqueness of situations and different medics’ needs, I will only discuss generic considerations regarding its implementation. During pre-mission planning, you should be aware of the following:
Enemy Situation(e.g, barricade, Meth-lab, etc.)
Severity of wounds/injuries (e.g., understand MOI, and injuries you may encounter)
Number of casualties (e.g., number of assaulters on the objective, suspects, etc.)
Response time (i.e., are you close to a Trauma Center, what is the response time of air)
Platforms available (e.g., horse cart, truck, and helicopter)
Level of care on Platforms available (i.e., is there a PA onboard, EMT, medic)
Travel time to next level of care
Obviously the above-mentioned will be in constant flux. Also, you will not know all of these beforehand (e.g., severity of wounds). However, you can assess the types of injuries you may encounter due to the type of mission, then plan accordingly with the type of gear you carry and your prepositioned equipment on a dedicated evacuation platform. For example, if conducting an assault and inserting via fast-rope, then you may encounter long-bone fractures. You would not carry a splint in your assault bag. Instead, leave it on the evac-platform in your level 3 kit. Another example would be a suspected meth-lab. You may encounter inhalation injuries. Therefore, you would have the requisite equipment for treatment on the evac-platform.
Once you have initiated an evacuation, you should consider the following when prepping a casualty for hand-over:
Remove Load bearing equipment
Mission Essential Eqt stays in the field (e.g., ammunition, radios, weapons, etc.)
Bag and tag all other effects (laundry bags or 4-mil heavy-duty trash bags work well)
Lay out in priority – most critical will probably be loaded last
Ensure casualties are marked appropriately with casualty card and glow-sticks (if at night)
Protect your casualty: hypothermia prevention (blanket), Eye Pro, Ear Pro, strap them to the litter, secure IV lines
Hypothermia is of concern in hot climates as well. Studies from Iraq indicate that in temperatures over 120 F, casualties are arriving at surgical units hypothermic. You do not need to use external heat sources (e.g., heatpacks) if you PREVENT heat loss at the point of injury. You must prevent so you do not have to rewarm.
Providing care under fire is a mentally daunting task. Few other phases have so little to do with medicine and so much to do with your surroundings. Even with a sizable piece of cover, it is easy to make mistakes and expose yourself during treatment when focused on patient care.
In the video you can see the medic doing a decent job of maintaining a low profile during treatment, then, while shifting from the casualty’s leg to his head, he elevates his body during movement. This action briefly exposes his head to enemy fire. An analogy we like to use to explain the atmosphere you are operating in when providing true “care under fire” is that it can be equated to working in confined space. The difference is that instead of bumping your head or elbow on a concrete slab, the concrete slab is replaced by incoming fire. It is generally best for everyone if the medic avoids bumping parts of his body into bullets.
The effort to maintain your position of cover is exponentially more difficult in urban areas or areas with varying points of elevation. You should regularly reassess the effectiveness of you position as the fight progresses. If the enemy force has moved to an elevated position, or possibly to the second or third story of a surrounding structure, you just lost about 50% of your position. Now you must either be more cautious when moving to provide treatment or you need to shift to maximize the use of the position you are in. If in a structure with external windows and “plunging fire” from surrounding buildings, the safest position is on an external wall, in the corners, away from windows. However, remember to consider the type of materials used to construct the building before selecting this position. This position is not recommended if in a vinyl-sided home or a 3rd world type structure.
Failure to practice working in tight quarters behind cover can lead to potentially fatal mistakes in combat. Incorporate these situations into your training and use them to increase the effectiveness of your equipment (e.g., how and where you store or pack it) and how to asses your positions.
Here are some tips for operating in this phase of tactical medicine:
-Keep items required for Care Under Fire or buddy-aid easily accessible.
-Reposition casualties to minimize their level of exposure and yours.
-Don’t lose touch with your surroundings, regularly reassess the enemy’s position.
-Don’t be afraid to move to a new position if the tactical situation allows.
-If in a structure, be mindful of interior and exterior threats.
-Keep your treatments as simple as possible then get back on your gun!
It is important to understand that science has not yet isolated the compounds essential in the production of fairy dust. Modern hemostatic agents require proper technique and training to function properly. Simply placing these products onto or into wounds does not solve all of your problems. If members of your organization are issued hemostatic agents, it is essential that they are trained on the agents and fully understand their limitations.
There are four steps you ought to follow when using hemostatic agents:
1) Prep your equipment. Set yourself up for success by having all required components ready before addressing a bleed (i.e., agent, gauze, and bandage).
2) Identify the bleed. Placing or pouring an agent onto or into a wound without identifying the bleed is unwise. If you have a large cavity that requires hemostatic agent, you must make sure the agent is placed DIRECTLY ONTO THE damaged vessels in order for it to work. Otherwise, you are wasting blood cells and agent.
3) Proper placement. After identifying the bleed, you must ensure the agent is placed DIRECTLY ONTO THE BLEEDER. If you do not, you run the risk of creating a “crust” made of blood and agent above the vessels. In so doing, you have visibly stopped the bleeding by forming a large clot, but it has not stopped the bleed.
4) Pressure. Hemostatic agents do not relive you of the basics that are required for hemorrhage control. After using a hemostatic agent, you MUST place gauze behind it in order to create pressure, so as to allow a clot to form. Otherwise, you run the risk of the agent being washed away or of a “crust” forming and creating a hematoma. It is also necessary to use the gauze to hold the agent in place and prevent it from shifting during patient movement. A minor shift during movement can cause a re-bleed which could be fatal if overlooked during re-assessments
1) Can the basics stop the bleed?
2) Is the casualty hypothermic? If so, clotting is a factor.
3) External environmental factors. For example, wind (or rotorwash) may blow a powder agent into the casualty’s or your eyes.
4) Location of injury (e.g., face, neck, abdomen).
5) Staying basic with the basics
6) Training is a must. If end-users (i.e., medics, operators, officers) do not know the basics of hemorrhage control, then using hemostatic agents is not wise.
The ability to pack a wound is an essential skill for the tactical medic. While a tourniquet is an excellent tool for controlling hemorrhage in extremity trauma, there are many areas that do not allow proper application of a tourniquet. The video on wound packing was produced to show the fundamentals of wound packing.
A. Identify the bleed
B. Pack into the bleed
C. Pack tightly to the bone if possible
A. Identify the bleed-
It is essential that the medic identify the source of the serious hemorrhage. Simply stuffing gauze into a cavity is not always effective. Often times the pressure is not applied where it is needed and the gauze only acts as a sponge. What makes packing a wound effective is that is provides focused pressure directly on the damaged vessel. By occluding the lumen of the vessel with the gauze you get hemorrhage control. If it is not completely controlled it at least slows the hemorrhage to a point where the body’s natural clotting factors can interact with the gauze to form a clot. There are three main methods to identify the location of a bleed.
Visualization is the preferred method, but it is often unrealistic due to ballistic patterns, flooding of cavities and tissue movement. Excess blood filling the cavity can be scooped out to give a quick look, but on high pressure bleeds and blast injuries this can be very difficult.
2. Tactile assessment
Feel works well if you are in a relatively calm mental state and have complete awareness of your senses. It is not a reliable source when you have been carrying heavy loads, firing weapons for long periods of time or participating in any activity that has caused your hands to fatigue. It’s also unreliable if you are wearing multiple layers of gloves.
A basic understanding of the vascular structure of the human body goes a long way in this situation. It isn’t as good of an indicator as visualizing the bleed, but if you are pressed for time it can be a good solution. It is best when used in conjunction with the other methods. It is also helpful when determining the best angle to pack from.
B. Pack into the Bleed
Notice what the section is titled, “Pack into the bleed”. It does not say pack into the wound. Your first few sections of gauze should go directly to the source of the major hemorrhage. After that hemorrhage has been staunched, the remaining gauze should be packed tightly around it to keep it in place. Your goal is NOT to create a sponge inside the wound, but a solid mass that applies pressure where it is needed. This is a very important point. An often-asked question is, “how much blood does the Olaes bandage absorb?” The answer is this: hopefully none. The purpose of bandages is not to absorb the most blood, it is to STOP bleeding, in order to keep blood where it needs to be: in the body. You don’t put bandages on to keep your vehicle clean.
C. Pack to the bone
The major vessels of the body are not inside muscular tissue! Most vessels run near the major bones in the body. If the wound is in a location that allows you to use the bone as a rigid object to maintain pressure on the damaged vessel, use it. Start by packing into the bleeder, and then use the gauze to squeeze the vessel between it and the bone. This creates the same effect as a vascular tourniquet, or simply holding pressure with your finger.
Educating medical directors and command surgeons in the importance of wound packing is essential. The ability to pack wounds is a necessary skill in an environment with the potential for delayed evacuation times and limited manpower. The idea that you will hold direct pressure for 3-5 minutes during a fire fight is ridiculous. Packing a wound reduces the need for this and frees the medic’s hands up to engage more important things, like the enemy. When used in conjunction with hemostatic agents, it is even more effective. We will cover how these two work together in a future entry.
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.
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
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.