By: Bill Lewitt. (reprinted from The Art Of Instruction)
In the following material Bill Lewitt does an excellent job discussing trauma management and the various life saving devices that are on the market that can be used by an instructor in a situation where there might be an injury on the range. Keep in mind that no matter what environment you teach in, there is potential for injury, sometime severe. It is your job to be prepared to handle the situation, because you are in charge! Pay particular attention to what Bill mentions about the IFAK culture and the fact that most people who have a good emergency kit rarely know how to use it.
Enter Bill Lewitt:
Since the earliest days of Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF), countless lives have been saved by enhanced first aid skills applied in the field—mostly by non-medical personnel. In the same period of time, the number of terrorist-style attacks on civilian populations has increased at an alarming rate. Civilian first-responders are more and more being asked to treat military-grade injuries.
Whether the result of an improvised explosive device (IED), such as those used in the Madrid, London, and Boston—or small arms like the attacks in Mumbai, India, Fort Hood, and the Westgate Mall attacks in Nairobi, Kenya—a great number of potentially lethal injuries can be caused in a very short period of time. For those of us who have decided to become legally armed, the most often cited reason is a desire to keep ourselves, our family, and our community safe from these kinds of violent incidents. While marksmanship is an important part of the equation in stopping the threat and preventing further casualties, it is not the only skillset necessary to prevent loss of life. To illustrate this point, we can look to two recent acts of domestic terrorism: the Fort Hood murders committed by Nidal Hassan and the Boston Marathon Bombing.
In the November 2009 shootings at Ft. Hood, Hassan, who was armed only with a pistol, shot and killed 13 people and injured 30 more. Unlike many mass-shootings where the murderer takes his own life, Hassan exchanged gunfire with two officers before being taken into custody. One officer was gravely injured. The entire incident lasted roughly 10 minutes. Eleven of the 13 victims died on-scene, and two more died at an area hospital.
During the initial attack at the finish line of the Boston Marathon, there was no active threat to be engaged. Three victims were killed instantaneously, and 264 were treated at local hospitals—many with life-threatening traumatic amputations and serious bleeding. The attack took roughly 12 seconds. After the bombs exploded, there was no danger of further injury. The skill necessary at that point was the ability to stop bleeding by any available means.
The IFAK Culture
Since the introduction and popularization of the Individual First Aid Kit (IFAK), there has been an explosion in awareness around the necessity for medical kit and training. It seems most often, however, that in the race between “kit” and “training,” kit almost always wins out. I have been teaching one version or another of my Basic Trauma Management for Shooters program for 13 years. I always invite students to bring their first aid gear to the class so we can look it over together. When I first started teaching at the Sig Sauer Academy in 2001, very few students arrived with their own kit. Now it’s very common to have guys running some kind of small IFAK on a chest rig or a pistol belt. That’s a big improvement, but at least 75% of those students show up with their tourniquets still sealed in plastic. This is simply unacceptable. The skills necessary to perform lifesaving first aid on a trauma victim are not complex, however the time to practice them is not in the middle of a critical incident. Just like any other skill that you want to be able to perform under duress, it needs to be hard-wired before you need it.
The contents of the IFAK vary widely based on who assembled it and the audience that the kit is geared toward. At the very least, the IFAK should contain enough supplies to treat two major bleeds, a tension pneumothorax, and be able to provide basic airway protection. I’ve designed every-day carry (EDC) kits for civilians, undercover narcotics officers, and low-profile advanced security details working in non-permissive environments. I’ve also spec’d out kits for civilian contractors working in Iraq, West Africa, and Southwest Asia, some without benefit of military support. These are different kits designed to function in very different environments. All of them, however, have one thing in common: they need to be able to stop severe bleeding. Death from blood loss accounts for nearly 70% of all preventable deaths in a tactical environment. As such, trauma management training and kit needs to focus on the rapid recognition and treatment of this threat to life.
The Renaissance of the Tourniquet
When I first became a paramedic in the mid 1990’s, the risks of using a tourniquet were made very clear: Life Over Limb. Tourniquets were only to be used in the most life-threatening circumstances, and even then it was expected to cost the victim an extremity. In the last 14 years, research conducted by the U.S. military has proven beyond any doubt that not only are tourniquets life-saving, they are safe and should be considered as first-line therapy for severe bleeding. According to the United States Army Institute for Surgical Research (USAISR), a tourniquet can be placed on a victim for between six and eight hours with very little chance of injury to the limb. In some extreme circumstances, such as the Battle of Taku Ghar (also known as Roberts Ridge), tourniquets have been left in place on victims for up to 24 hours prior to evacuation to a surgical center. In this example, however, the victims were receiving ongoing care from USSOCOM medics, including USN SEAL Corpsman and USAF Pararescuemen.
Of all the currently available commercial tourniquets, I prefer the Combat Application Tourniquet, or CAT. Tens of thousands of these tourniquets have been placed on soldiers in Iraq and Afghanistan. I feel that they are highly effective and can be placed quickly both one- and two-handed. USAISR has published many studies where the CAT has performed as well or better than many of the tourniquets on the market. Combined with their durability, compact size, and ease of use, this gives me a high degree of confidence in this piece of kit. Even though the CAT is meant to be a one-time-use device, I have had the same set of 12 CAT’s that I’ve been using for training for at least eight years now. Each one has been applied hundreds of times in dozens of classes and I have never seen one fail to perform.
One of the most significant and controversial advances in field care in my lifetime has been the introduction of hemostatic agents that can control severe arterial bleeding and prevent death. The newest hemostatics have come a long way from the first generation products. In the early days, chemical burns were caused by powerful exothermic reactions that created temperatures in excess of 200° F. (93-103° C). The two agents primarily seen today are Celox and QuickClot.
The newest generations of hemostatics on the civilian market generate little to no heat at
all. The mechanism of action in these products varies greatly; however I have a preference between the two.
Based on the available literature and my personal experience, I use Celox in all of my trauma kits. I feel it is the most appropriate hemostatic for the widest range of applications. Celox will work on trauma victims regardless of their blood’s native ability to clot. This is critically important to victims who may be taking potent blood-thinning medications or have various forms of hemophilia. It will also work in high-altitude and low-temperature environments that make it difficult for blood to clot. Celox also works well when victims have already lost massive amounts of blood and their clotting factors may already be depleted.
Celox comes in both granules and gauze. I personally feel that the gauze is a better choice. However, it requires a whole lot more of a gut check from the person applying it. Instructional videos show people dumping packs of powder into bloody wounds and then applying a clean dressing on top of it. This is an appealing but unrealistic scenario when confronted with massive arterial hemorrhage. Our natural inclination when we see something unpleasant is to simply cover it up. I’ve spoken to many combat arms troops deployed downrange who described how powdered hemostatics were applied in the field; the packet was dumped on top of the injury site and covered with a bandage. The reality is that with Celox gauze, you will likely have you get most of your hand down into a fist-sized wound in order to get the best results. Simply laying the gauze across the top won’t get the job done.
Hemostatics represent one of the most significant advances in trauma management in the history of the field. They also require specific and realistic training to ensure they are applied correctly. Remember, hemostatics are only to be applied after a tourniquet has failed to control the bleeding. Proper application may be the only thing in between the victim and a folded flag, and you need to train that way.
As of April 2014, Celox is approved for use by the Committee for Tactical Combat Casualty Care.
Chest Seals: Preventing the Tension Pneumothorax
After blood loss, the biggest threat to life in trauma is the Tension Pneumothorax, or the sucking chest wound. Any injury between the navel and the neck on the front, back, or side of the body can potentially cause a pneumothorax. Any time an injury opens the chest to the outside environment there is the possibility that, every time you take a breath, you will suck air in through the wound site. As more and more air becomes trapped in the chest, it can cause your lungs to collapse and eventually put pressure on your heart. This risk is multiplied when there are multiple entrance and exit wounds.
Chest seals are large sticky plastic pads similar to those in an automatic external defibrillator (AED). Most of the current generation of chest seals have a vent built into them so that it may be possible that, as pressure builds up in the chest, it may be released and prevent the collapse of the heart and lungs. When they are applied over a chest injury, they prevent more air from being pulled into the chest. If there are multiple wound sites on the chest or back (such as multiple entrance wounds, or entrance and exit wounds) cover the biggest hole with the vented part of the chest seal. If you need more coverage you can use the wrapper that the seal came in (the inside of the wrapper will remain sterile as long as the package is not compromised).
The skill that goes along with applying the chest seal should always be the needle chest decompression. This surgical procedure is performed by inserting a very large, very long IV catheter between the ribs. This allows the pressure that has built up inside the chest to release and should in theory make it easier for the victim to breathe and restore blood pressure if it has started to drop. Although the needle chest decompression (or chest dart) has long been taught in the military Combat Life Saver (CLS) program, it is very controversial in both the civilian and law-enforcement community. Though it is not a complicated skill to learn, there are pitfalls and significant risks associated with it, such as nicking an artery. Additionally, the chest decompression may only be a speed bump. They may to have the procedure repeated, depending on the severity of the injury.
My record is seven—three on the left chest and four on the right. You should expect that a critical trauma patient is going to exceed the limitations of your IFAK and train accordingly.
Nasal Airways: Protecting the Unconscious Victim
Back in the dark ages, if a victim at a Mass Casualty Incident (MCI) couldn’t breathe on their own, the rescuer was obligated to make one feeble attempt at opening their airway and then was expected to move on, leaving them in God’s hands. Since the introduction of the IFAK, there has been at least a nod toward preventing the unconscious victim from suffocating to death. Most modern IFAKs include a nasopharengeal airway (NPA), affectionately known as the nasal trumpet or the nose-hose. The nasal airway is designed to be used for the unconscious victims of trauma, giving them at least a nominal chance of not choking to death on their own secretions. It is slid (ok, pushed!) into the largest nostril, and the victim should then either be sat straight up or rolled over face-down into the recovery position. This will help to ensure that blood, vomit, or mucus doesn’t block the airway.
My rule is simple; if victims can’t fight you off when you try to place the nasal airway, then they need it. If you don’t believe me, I’ll give you one for free and you can try it on a friend! I just ask that you send me a video!
Beyond the IFAK: The Limitations of Kit
First aid gear is not a good luck charm. Buying it does not improve your survivability or readiness. You have to train with it. You can’t just throw your money at gear and consider the problem solved. If you run a weapon-mounted light, you need to train with it in low-light conditions. Same with anything else you bolt onto your gun or tie town to your plate carrier. Medical skills are no different. Trauma Management training should cover both self-aid and buddy-aid. Ideally, you should be able to perform all skills one-handed both on your strong and support side, and the same goes for weapon handling.
In both of the terrorist incidents outlined above, there were dozens of critical victims on scene. This illustrates a few key points. First, and maybe most importantly, EMS and other first responders will be overwhelmed. It will take time before you or your loved ones get treatment. Second, it is likely that there will be many more victims than you have equipment to help. The ability to improvise effective bandages and tourniquets will save lives.
During the 2011 mass murder in Oslo, Norway, 69 victims were murdered and 110 were injured on island of Utøya. Rescue efforts were hampered by the remote location of the event and the large area that the victims were scattered over. How many of the victims were not killed outright, but bled to death, choked to death, or died as the result of a pneumothorax awaiting basic first aid? The simple answer is too many.
Ideally, an introductory trauma management class should be taught in the context of gunfighting. I say this because most of us are trainers, armed professionals, or legally armed citizens. The focus of this skillset should be winning not only the fight, but the aftermath. This should include strong and support hand shooting, weapon transitions, reloads, clearance drills, and shooting from the deck. Medicine never comes before tactics. Students should be pushed to fight injured and engage threats even while the injuries of others are going untreated, even if the victim is a family member or a teammate. Only when all tactical concerns are satisfied will aid be rendered. Students should be taught self-aid and buddy-aid and be able to perform these skills in adverse conditions (e.g. one-handed, in the dark, etc.).
A class should cover the use of everything in an IFAK and should address the three most common preventable causes of death from trauma: uncontrolled extremity hemorrhage, the tension pneumothorax, and airway compromise.
A tactical first aid program is not an EMT class. You shouldn’t be learning how to take blood pressures, how to recognize a brown recluse, or how to apply a cervical collar. It is also not a military Tactical Combat Casualty Care (TCCC) class. Fire superiority may be the best “medicine” on the battlefield, but I can’t frag out because someone caught an ND on the range. Training has to be appropriate and in context for the student.
Lastly—and this has earned me a letter from PETA—trauma management training should include a wet lab utilizing blood and tissue. I can only teach so many things in an eight- or sixteen-hour class. I can’t make you a paramedic, and I can’t teach you everything I’ve learned in the las
t 20 years, but I should be able to show you exactly how horrific a serious injury is and how to treat it so that you don’t vapor-lock when you see it. Nature favors initiative, and while trauma management at this level isn’t complicated, it has to be done right, and it has to be done quickly—otherwise lives will be lost.
Many of us believe that by making the decision to arm ourselves we have taken on the responsibility for the safety of those around us. Some of us carry a weapon for a living. Regardless of the reason you choose to be armed, the assumption is that you may someday have to respond to a lethal threat. Why then, after acknowledging the fact that you may become involved in a lethal force encounter, do so many of us refuse to take the next logical step and learn how to treat the injuries that result from armed violence?
Basic first aid skills are a must for any responsible adult, let alone for those who are armed. The skills you learn in any tactical first aid program will still apply to any other form of trauma you may encounter, not just those that result from violence.
It’s my sincerest hope that none of my students never need any of the skills that I teach and that the contents of your aid kits expire and yellow untouched in their plastic, but for some of us, that won’t be the case. You’ll know immediately when that day comes. I hope you’re ready.
MSN, RN, Critical Care Paramedic