Equipment Considerations: Level 2

As mentioned in an earlier post regarding Level 1 kit, you must pack your medical gear to reflect the mission requirements and constraints. Here are some considerations when packing your Level 2 gear:

1) Pack supplements to Level 1. For instance, medics may need more bandages and tourniquets.

2) Pack for Tactical Filed Care phase of treatment. In this phase, you may need:

    A. Drugs (e.g., Toradol) and associated items (e.g., syringes, heplocks)
    B. Splinting material
    C. Evacuation Platforms (e.g., poleless litters or a Foxtrot Litter)
    D. Fluids
    E. Needle Thoracostomy items
    F. Hypothermia Prevention
    G. Casualty Equipment Bag
    H. Casualty Documentation

3) An aid-bag for the above items. Err on the side of too small, as carrying a “tick” on your back might be more of a burden than an asset, depending on the mission. That is your call.

The above serves as a framework. We will cover Level 3 in the next post.

Needle Decompression Hazards

Historically, tension pneumothax has been the 2nd leading cause of preventable death on the battlefield. Therefore, this is an important skill and is being taught to medics at the lowest level of care. However, as with all procedures, risks are involved. Feedback from the field has indicated that medics are performing this procedure too often and TOO medial, causing multiple complications.

The above video covers the hazards of a needle decompression. Below you will find a brief review of indications, contra-indications, etc. As always, please follow local protocols.

Needle decompression is indicated for the treatment of:
A. Tension pneumothorax and / or
B. Tension hemopneumothorax

A. Chest decompression is indicated in the field only in the face of a life-threatening
tension pneumothorax. In that situation, there are essentially no contraindications since
the only alternative is almost certain death.

A. Blunt force trauma to the chest that ruptures a portion of lung tissue
B. Fractured rib that punctures the lung tissue
C. Spontaneous pneumothorax for no apparent reason
D. Conversion of a simple pneumothorax to a tension pneumothorax by positive pressure
ventilation as with a bag-valve mask device etc.
E. Open pneumothorax that is covered and left unattended developing into a tension

A. Chest pain
B. Severe respiratory distress
C. Tachycardia
D. Hypotension
E. Decreased or absent breath sounds on affected side

A. Cyanosis
B. Distended neck veins
C. Tracheal deviation away from affected side

Pic 3
(Source: Canadian Tactical and Operational Medical Solutions)

A. Creation of pneumothorax where none existed previously
B. Laceration of lung tissue
C. Bleeding from laceration of intercostal blood vessels
D. Severe pain to conscious patient (since this is life-threatening, the procedure must be
continued )
E. Local hematoma
F. Laceration and/or puncture of the heart

Tactical K-9 Care: Part 2

As noted in the Tactical K-9 Care: Part 1, a tactical medic may be the only care provider able to assist a working dog that has been injured. The goal of the following article is introduce medics to common trauma associated with working dogs in a tactical environment. As previously suggested, medics ought to find a veterinarian that has experience with working dogs and work with them to become more familiar with anatomy and what is “normal” for canines, as well as become comfortable working with them.

The following article is from the Journal of Special Operations Medicine, vol. 9, edition 2, pg 14-21.

Care of the Military Working Dog Part 2

Tactical K-9 Care: Part 1

In the tactical environment, a tactical medic may be the only care provider able to assist a working dog that has been injured. The goal of the following article is introduce medics to common problems associated with working dogs in a tactical environment. In addition to this article, medics ought to find a veterinarian that has experience with working dogs and work with them to become more familiar with anatomy and what is “normal” for canines, as well as become comfortable working with them.

The following article is from the Journal of Special Operations Medicine, vol. 7, edition 2, pg 33-47.

Care of the Military Working Dog

Tactical K-9 Care: Part 2 will focus on treatment of trauma.

MCI Injury Patterns and Treatment


Bombs aimed at civilian populations are the most common
weapon used by terrorists throughout the world. Over the last
decade, we have been involved in the management of more
than 20 mass casualty incidents, most of which were caused
by terrorist bombings. Commonly, in these events, there may
be many victims and many deaths. However, only a few of the
survivors will suffer from life-threatening injuries.
and timely treatment may impact their survival. Due to the
complex mechanism of injury seen in these scenarios, treatment
of victims injured by explosions is somewhat different
from that exercised in blunt and penetrating trauma from
other causes. The intention of this article was to outline the
initial medical treatment of the injured victim arriving at the
emergency department during a mass casualty incident
caused by a terrorist bombing. Treatment protocols for stable,
unstable, and in extremis patients are presented.

MCI Stable Victims

Improvised Medicine: Part 2

In a previous entry, we discussed improvising in the field and demonstrated a method of creating a scalpel handle out of its wrapper. This entry will focus on the safety pin and several of its uses. It’s always a good idea to have 4 or 5 of these in your kit. They can be used to solve many medical and non-medical problems. They are inexpensive, don’t expire, and take up hardly any space.

Here is a list of a few things you can do with a safety pin:

-Pin the tongue to the lip to maintain the airway
-Splint a finger
-Make a sling out of a casualty’s shirt
-Close abdominal wounds or large lacerations
-Make a tracheal hook
-Secure an ET or Cric tube.

Like most improvised medicine, these techniques are not definitive treatments, but in certain situations you may not have any other option. You can never carry everything, so knowing how to employ items you have can be a life saver…literally.

S.W.A.T. Tac Med Course

A new training company is offering a course in Florida for those interested in attending. The company is formed of current and former Military and LE personnel. Here is an excerpt from the course flyer and a link:

Sign up today for an intensive program geared towards the certified Tactical Medic Provider. This 24hr course over 2 days will provide you an opportunity to evaluate your current skill level in both the medicine and tactics involved in SWAT missions.

SWAT Medic Flyer

Casualty as a Fluid Infusion Device: IV Bag Placement


This study was designed to identify the most effective underbody
position when using the patient’s own body weight as an
infusion device. Twenty volunteers had an air-less 500ml bag of
saline located at various under-body positions. Mean pressures
and flow rates through a 14G cannula were measured in vitro at
room temperature. Locating the fluid bag at the buttock cleft
delivered the highest mean flow rate at 135ml/min. This underbody position may provide flow rates sufficient to achieve the clinical aim of fluid resuscitation in the military pre-hospital

Fluid Infusion IV Bags

A dictum of tactical medicine is to carry equipment that has dual use. In the case of fluid infusion, medics are instructed to use their blood pressure cuffs or the patient if no other device is available. Medics have the option of carrying pre-made fluid infusers or an extra BP cuff, but the former violates the rule of dual use and the latter may be too bulky. The above article offers a valid, though not new, solution, because it explores the best location if a medic chooses to use the casualty.

TCCC 2009 Guidelines

You will notice WoundStat has been removed as the secondary hemostatic.

TCCC 2009 Guidelines

Surgical Airway/Cricothyroidotomy: How to

This video is a supplement to training and is neither comprehensive nor a replacement for proper instruction.

A surgical airway/cricothyroidotomy is the advanced airway of choice in combat, due to the types of injuries encountered. Severe maxofacial trauma secondary to blasts are common and may require more invasive treatment when neither the recovery position nor NPA nor King Oropharyngeal Airway (King-LTD) will suffice. It is important to note that only airway management is generally best left to the Tactical Field Care (TFC) phase of treatment. Furthermore, less than 1% of trauma casualties require an airway, so prudence is required when deciding to intervene. The indications and contraindication are as follows:


–Airway obstruction due to maxillofacial trauma that cannot be corrected by positioning or a nasopharyngeal airway
–Anaphylaxis that is or is about to compromise the airway
–Inhalation burns injury
–Where other means to secure the airway have failed


–Airway can be maintained by other means

Please note that we illustrate a vertical incision instead of the traditional horizontal, because we feel it is the preferred method in the tactical environment. First, a vertical incision minimizes the risk of involving (e.g., cutting) the vascular structure of the neck. Second, it creates a larger “window,” thereby simplifying landmark identification. Finally, a vertical incision allows one to select a different location above or below the initial site, if one should misplace the initial cut, due to lack of familiarity with the procedure.