Let’s talk trauma part IV: Considerations for trauma injuries in SHTF/WROL

Flying monkey Wing Attack Plan R.

Flying monkey Wing Attack Plan R.

Today we’ll look at what types of trauma injuries would be most likely in a SHTF/WROL scenario where Bolshevik flying monkeys have nuked your metro area and are putting the squeeze on the outlying areas in an attempt to impose a flying monkey worker’s paradise in your town.

Let’s do some cursory exploration of wound types in our wars in Afghanistan and Iraq:

The United States forces in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) are primarily engaged in counterinsurgency operations within an irregular war. The US combat medical experience has reported new injury patterns secondary to the enemy’s reliance on explosive mechanisms, particularly improvised explosive devices (IEDs), and the widespread use of individual and vehicular body armor. Musculoskeletal extremity injuries have been reported to comprise approximately 50% of all combat wounds for OIF/OEF. Utilization of individual body armor has dramatically reduced thoracic injuries and has decreased the lethality of gunshot wounds, as measured by the percent killed in action, which in conflicts prior to OIF/OEF was estimated at 33% but is now 4.6%. Explosive mechanisms of injury, with IEDs being the most common, account for over 75% of all combat casualties. The lethality of IEDs coupled with the protection of the thorax and abdomen provided by individual body armor has resulted in increasingly severe orthopaedic injuries. Collection and careful examination of orthopaedic combat casualties will allow for improved military personnel protective measures and treatment of injured soldiers. (Journal of Surgical Orthopaedic Advances 19(1):2–7, 2010)Source: LTC Philip J. Belmont, Jr., MD, MAJ Andrew J. Schoenfeld, MD, and CPT Gens Goodman, DO, Epidemiology of Combat Wounds in Operation Iraqi Freedom and Operation Enduring Freedom: Orthopaedic Burden of Disease, Journal of Surgical Orthopaedic Advances, Copyright 2010 by the Southern Orthopaedic Association

Below are some graphs from the above referenced report that compare causes of wounds and body areas affected from US wars since the Civil War.wound-mechanismwound-distribution

The distribution of wounds in soldiers WIA [wounded in action] is reflected by the different mechanisms of injury. Gunshot wounds most commonly involve single body regions (e.g., head/neck, thorax, abdomen, or extremities) and characteristically have a single entrance and exit wound. In contrast, explosive injuries tend to simultaneously affect multiple body regions….Owens et al. (11) also reported that explosions were responsible for 75% of orthopaedic injuries, while gunshot wounds accounted for 16%. Fifty-three percent of wounds were penetrating injuries to the soft tissues and a further 26% were fractures (11). Eighty-two percent of all fractures were found to have been open injuries (11). Fractures and soft tissue injuries were evenly distributed between the upper and lower extremities, with hand fractures being the most common fracture type in the upper limbs and tibia–fibula fractures most common in the lower limbs (11)…Over the course of the 20th century, a generalized trend has occurred whereby the number of casualties due to explosives has increased relative to those caused by gunshot. In World War I, 65% of all recorded combat casualties resulted from gunshots (21). This decreased to 35% during Vietnam (22) and has been reported to be between 16% and 23% in recent studies of OIF/OEF (9, 11). An analysis of the epidemiology of injuries in OIF/OEF documented that 81% of all injuries were due to explosions (19). The 16%–23% casualty figure for ballistic trauma during OIF/OEF represents the lowest proportion of military wounds from gunshots in history (9, 11, 19)

Now, this report is dealing with wounds inflicted on our uniformed forces by insurgents and irregulars. I have not had the chance to research the trauma epidemiology of our foes and what types of wounds our guys inflicted on them, but I have to believe that with the combined arms operations (close air support, artillery, armor, infantry, etc.) employed by our side, we’re killing and wounding a lot of shitheads with explosives as well. Since Americans know how to shoot, I would posit that the infliction of wounds by gunfire is higher, but explosives probably still win the day. I’ll do more research on that when I have a chance.
What this very brief view into the wound epidemiology does is give you a good idea of what methods proved to be effective to wound and kill people in a counterinsurgency / insurgency battle. I encourage everyone to do some reading over at Selco’s site and FerFal’s site to get some experiential information on what happens in a SHTF/WROL scenario in what were classified as First World societies and how quickly savagery took over.
Look at Ukraine after the peaceful protests ceased being peaceful. Going on what news and information one could glean from the Internet and traditional media sources, in addition to gunfire, blunt trauma-causing weapons, and flame weapons of the most primitive order were employed with aplomb.
Don’t forget Africa, oh lovely Africa, especially Rawanda. The conflict there illustrates clearly the folly of gun control. Gangs with machetes were very effective at stacking dead bodies like cordwood, showing that the weapon is truly the mind of the man wielding an object as a tool to facilitate death. The more primitive the war, the more primitive the wounds. Punctures, giant lacerations, avulsions, amputations, fractures, and cleaved heads will be a common occurance.
In a Total War scenario, where a state goes on a war of extermination, the guerrilla force is going to have a very tough time, since carpet bombing everything, everywhere, and salting the earth when you are done is part of the playbook, Geneva Conventions be damned. So we’re not going to cover that, although I have a feeling injuries from explosives, nuclear and otherwise, will be ubiquitous.
Let me preface that I am going to cover wound types and treatment concerns in a very general, philosophical manner. It will not be a detailed instruction for treating, as I believe there are excellent resources already out there that you can download / buy, and more importantly, people who can train you to do these things in-person, which is the best knowledge transfer of all. You may want to re-read Part II (or read it the first time if you haven’t) since more specific information on how to fix life threats as part of the rapid trauma assessment is included.

Blast injuries

Blast injuries from explosions have three phases:

  • Primary injuries: The overpressure or pressure wave from an explosion. This hits the fastest, and will cause damage to the inner ears, lungs, and every hollow organ in your body (intestines, stomach, etc.) if you are close enough to the blast.
  • Secondary injuries: This is the fragmentation wave that sends shrapnel everywhere and causes massive soft tissue damage from penetrating and puncture wounds. Amputations happen here.
  • Tertiary injuries: This is the “blast wind” that will throw people around and into things. Depending on the force of the explosion, this can be an extremely deadly phase.

As indicated by the article above, a person who is subject to an explosion is going to have multiple traumatic injuries at once, including traumatic brain injuries. When you add burns and burn damage to the airway from a blast, you understand why these weapons are so deadly, and why they are the choice weapon for insurgents fighting a conventional military force.

Key to treating these injuries is to remember your rapid trauma assessment and fixing the immediate life threats as you find them. The mental state of your patient is going to be very important on these, as the more debilitated he is, the more severe the injury may be to his brain. Always be suspicious of cervical spine injury with these. Take c-spine precautions immediately and work in a field neuro exam to test for injury along the spine. Infection is a huge concern because of open fractures, amputations, penetrating wounds, and the mixture of dirt, fuel, explosives, other people’s body parts / blood mixing in with your patient’s wounds. Once stabilized, massive doses of antibiotics and debridement of burned and heavily damaged flesh is critical. Definitive treatment at a specialty center is absolutely required. These injuries will test all of your skills and your mettle. You will need to work fast and always keep the triage priority in mind.

Notice all of the debris, dirt, and viscera on the scene. These same things end up inside of your patients.

Airway injuries

These are injuries that compromise the patient’s ability to get air into his lungs to breathe. With explosions and burns, you need to look around the patient’s nose and mouth for soot and/or swelling indicating he inhaled hot gases. Your concern here is that his airway may swell shut and it’s game over. It’s critical to get an advanced airway that isolates the trachea in place BEFORE the swelling gets bad in these patients. Supraglottic airways like Cobras, Kings, and LMAs aren’t effective because they sit in the esophagus and are of no use if the trachea swells shut. If the patient is conscious, has a gag reflex, and is still breathing on his own, you may be able to insert a nasotracheal tube, or use rapid sequence induction if you have the training and the drugs to do it. If the patient is unconscious with no gag reflex, a regular endotracheal tube is what you need.

In a patient has seriously altered mental status and is at risk of aspirating blood, vomit, or anything else into his lungs, you’ll need an advanced airway.

Severe facial trauma is scary, and something you’ll see in an environment where explosions are happening and bullets are flying. Nasotracheal (NT) tubes are a no-no in this case, as the patient may have a basilar skull fracture, and your insertion of the NT tube into his nose may end up in his brain, and that’s bad. In the rare cases where someone we’ve encountered has been less than successful with a gun-under-chin suicide and blown his lower jaw off, we have the saying “aim for the bubbles” when it comes to getting the airway. This is also the scenario where the surgical cricothyrotomy may be indicated. This is a procedure – bluntly stated – where you cut a hole in your in a space in your patient’s Adam’s apple and insert an endotracheal tube directly into the trachea. If you are having to do this, your patient’s day and your day sucks.

Advanced airways are, in my mind, part of the cool-guy gear contingency. This is good and bad. If I can easily ventilate a patient with a bag valve mask and keep him perfused adequately until disposition to definitive care, I am staying with that. If I have a patient who is still breathing on his own but has an airway that is in danger of being compromised, I would choose a nasotracheal tube (NT) as my first course of action before performing rapid sequence induction (RSI), where you sedate your patient, completely paralyze him, including his ability to breathe on his own, with paralytic drugs, insert an endotracheal tube using a laryngoscope, and assist him with ventilations for as long as he is your care. An unconscious patient that isn’t breathing is getting an ET tube, no drugs needed unless we resuscitate him and he needs sedation to keep from pulling the tube out. I make very sure that my decisions on airway are based on getting the right physiological outcome and minimizing risks to the patient. Taking away a guy’s ability to breathe on his own is a hell of a responsibility and should be done with proper consideration.Treat that patient as you would your wife, kids, or relatives in this situation, and don’t be cavalier about what you use to keep their airway open.

Keeping the SHTF/WROL scenario in context, if you are in the middle of nowhere with minimal access to rapid transport and specialty centers, the prognosis for your patient needing an advanced airway is  poor.

Brain injuries

The 13 years of war and the use of IEDs by the man-jammie crowd has created a high incidence of traumatic brain injuries (TBIs) in our wounded guys. I’m going to cover three injuries very briefly. The treatment for all of them is essentially the same. Put the patient in full spinal immobilization and get them out of the fray. The reality is, a mild TBI like a concussion can have the same initial presentation as an epidural bleed, which can kill you pretty dead, pretty fast. If you are able to differentiate what kind of TBI your patient has in the field, it’s probably because he’s dying in front of you. These injuries require rapid transport to emergency care where a CT scan can be done on the head to help diagnose the injury and give the patient definitive care.

Concussion: Your patient gets knocked out for a short period and wakes up confused. This state of confusion can last anywhere from under 30 minutes to over 24 hours. He may be dizzy, sleepy, and nauseous after the injury. If those symptoms continue or get worse, he may have something a lot more serious. Remember your rapid trauma assessment and focus on the AVPU portion. Also make sure you are looking for dilated pupils bilaterally or on one side. They may indicate the next type of TBI. If your patient only has a concussion, he will require physical and mental rest for a while. The level really depends on the severity of the concussion.

Epidural bleed or hematoma: Without going too much into the anatomy and physiology on this one, this can present very similarly to a concussion at the outset. The difference is that an artery has been damaged and is bleeding away in the space between the brain and the skull. Your patient will be knocked out for a short period, and may wake back up into a brief lucid period. Shortly thereafter, the effects of the bleed will take effect; extreme headache, dizziness, blurred vision, nausea, vomiting, weakness, seizures, and dilated pupils in one or both eyes. What’s happening is blood filling up space in the skull, pushing on the brain, and forcing it to herniate out of the opening in the back of the skull called the foramen magnum, where the spine and spinal cord connect to the brain. Without immediate treatment of getting the excess fluid out of the skull and stopping the bleed, this is a fatal condition.

Epidural hematoma on the left side of the skull. Note the pressure on the brain. If not fixed very soon, this will be fatal. Source: https://en.wikipedia.org/wiki/File:Epidural_Hematoma.jpg

Subdural hematoma: This is a venous (not arterial) bleed in between membranes that surround the brain called the meninges. A subdural hematoma is often caused by a rapid acceleration / deceleration event that causes injury to bridging veins within the meninges. Since it is a venous injury, the bleed is much slower than the arterial bleed epidural hematoma and the onset of symptoms is much slower. Like it’s arterial cousin, the subdural hematoma starts to fill the skull cavity with extra blood, causing increased pressure on the brain and inside the skull. Ultimately, the patient will have symptoms of headache, dizziness, nausea, vomiting, weakness, seizures, disorientation, and dilated pupils. There is high risk for brain herniation, and like the epidural hematoma, definitive care is rapid transport to an OR for surgery to stop the bleed and relieve the pressure. Without that, the prognosis is fatal.

Subdural hematoma on the right side of the skull. Left untreated, the prognosis for this is grim. Source: https://en.wikipedia.org/wiki/File:Subduralandherniation.PNG

Other things to watch out for with TBIs are the presence of cerebral spinal fluid (CSF) in the ears or nose. This indicates that something has broken the blood / brain barrier, and the shock-absorbing fluid that the brain floats in is leaking out of a fracture or penetration of some kind. Sean Parnell, the walking badass Ranger captain that wrote the book Outlaw Platoon chronicles how he got a TBI in a firefight in Afghanistan but continued to lead his men for weeks with CSF leaking out of his ears. He ended up being medically discharged in the end because of the extensive damage neurological damage done, but he lives today to talk about it. Crazy? Brave? Lucky? Probably plenty of each. In any case, don’t screw around if you see CSF, even if your patient is OK. Get them off the field and into care as soon as practicable.

Continued assessment of EVERYONE that you suspect of having a TBI is critical to their survival. Keep up on their mental status and treat with an over abundance of caution. Check a blood glucose level of a suspected TBI patient if you have the equipment because injuries to the central nervous system can cause it to gobble up massive amounts of glucose. An abnormally low BGL reading in a suspected TBI patient with no history of hypoglycemia can help you narrow your differential diagnoses.

Extremity injuries

As shown in the metrics above, these are the most likely injuries you will encounter if things are hot and the lead is flying. In blast injuries, be ready to deal with MULTIPLE extremity injuries on one patient. Refer to the rapid trauma assessment piece for procedures to stop bleeding and deal with open and closed fractures.

Here you will see punctures, tears (or avulsions), fractures of all kinds, amputations, burns of all kinds.

Key with these is preservation of motor and sensory function of the extremities as much as you can. If you can avoid cutting off circulation to a limb entirely with a tourniquet and stop bleeding with other measures, there will be a better prognosis for the patient. If you are dealing with an arterial bleed and the patient is fading fast, don’t screw around. Get that CAT-T on it and get on with it.

Bullet wounds will have cavitation damaging tissues in a much great area than the diameter of the bullet holes. The faster the projectile is going, the worse the damage will be.

See that? That bubble is flesh getting damaged from a bullet’s cavitation.

As mentioned before, infection is going to be a top-level worry. Getting the wounds cleaned and dressed is a top priority. Broad spectrum IV antibiotics may be needed. Minor extremity wounds can be treated in the field with attention to hygiene and regular reassessments of the patient and the wound.

Since we’re dealing with squads of imperfect people who may have different levels of physical ability running around doing things with heavy packs on their backs, be ready for strains and strains of ankles and wrists from people losing their footing and flopping onto the ground. Practice your splinting techniques when you get together with your team and see how well you move around with a guy limping along with a gimp leg. Have fun carrying his gear, too.

Thoracic and abdominal wounds

From the study above, we see that the use of body armor has helped reduce the number of wounds to the thorax (chest) and abdomen. Here are a couple of great illustrations I stole from AR15.com that show proper placement of rifle plates to cover the most vital areas of the thorax.

CHEST

thorax_anterior_800

BACK

thorax_posterior_800

As you can see, a good SAPI plate can prevent a lot of bad things from happening, but there are still enough vital areas exposed that can be of concern. In Part I of this series, we talked about hemorrhages, and in Part II, areas of the body that we need to be especially concerned about should somebody receive a penetrating wound, like in the pelvis, since there is a very high probability of massive blood loss. Rifle plates do a great job of covering the mediastinum, which in gross terms is the center of your chest containing the heart and the great vessels – the aorta and vena cavae. However, once you get outside of the SAPI plate, with great concern about the abdomen, you still have things like the descending aorta, the iliac arteries, the inferior vena cava, and of course, the spine.  For any patient that’s been shot in the abdomen below the SAPI plate, be on the lookout for massive internal bleeding and shock. Penetrating abdominal wounds are nasty, because in addition to tissue damage, whatever is in the small and large intestines is going to spill into the abdominal cavity if they are damaged. This is yet another cause for nasty infections. If your patient’s spine has been hit, he’ll complain about leg pain, weakness, numbness, or just plain not feeling anything below the wound site. Check for pulse, motor, and sensory function below the site of the injury. If you can get this guy into full spinal immobilization ASAP, that’s a good thing.  These patients need to be transported out to definitive care as well.

If your patient is hit above the SAPI plate in the clavicles, be suspicious of damage to the subclavian artery and vein that run underneath the clavicle. Damage to the patient’s trachea and neck are very serious and need to be dealt with immediately with special concern being the compromised airway. Be suspicious of a pneumothorax as well, since there is still enough lung poking around the side of the plate to cause trouble. Check and recheck your patient’s breathing rate, capillary refill, and AVPU routinely to ensure he is getting perfused.

There is still plenty of opportunity for a patient to experience extreme blunt force trauma to the chest and abdomen even with soft armor and plates in place. The armor helps mitigate it, but if the force is big enough, you can still wind up with a patient with serious internal injuries. Look for massive bruising developing wherever the blunt impact took place. If over the chest, be suspicious of pneumothorax, hemothorax, and pulmonary contusion – which is a bruise to the lung tissue itself. The pneumo and the hemo are air and/or blood filling up the thoracic cavity outside of the lung and compressing the lung. The pulmonary contusion is the vessels and capillaries in the lungs bleeding themselves. With this, you get blood in the lungs disrupting gas exchange at the alveoli. Be on the lookout for this after a blast as well. Be prepared to assist ventilations with a bag valve mask. In bad cases, deep suctioning may be needed to help get fluid out of the lungs.

Look for bruising in the abdomen after any blunt trauma and always be suspicious of liver lacerations, spleen lacerations, and damage to the great veins. If the patient’s abdomen becomes distended and he is presenting with signs of shock, this is an ominous sign of an internal bleed.

If nothing else, the wound potential to these areas should be motivation for you to get in enough shape to drop to prone and minimize your profile or be able to run fast enough to find cover should flying monkeys be hurling kinetic weapons at you.

Burns

Burns will always be a concern when angry people and Bolshevik flying monkeys are in conflict with each other. The Ukrainian resistance definitely lived up to their Kievan Rus heritage with the employ of the molotov cocktail.

As mentioned in the Blast Injury section, you FIRST concern with a burn patient is going to be his airway. Look for soot, redness, swelling, and blistering around the nose and mouth. If present, you need to secure an airway ASAP because this patient may have gotten a lungful of scorching hot gases and his airway is going to swell shut. If your patient is already complaining of having trouble breathing, trust him and know that his airway may be closing up. You need an airway that isolates the trachea, and this means either a nasotracheal or endotracheal tube, both of which are advanced airways.

Below is a very perfunctory breakdown of burn types.

Source: https://en.wikipedia.org/wiki/File:Burn_Degree_Diagram.svg

A first degree, or superficial burn is on the epidermis only. Sunburn? Touch a radiator? Redness and a little swelling? Pain? That’s what it looks and feels like.

A second degree, or partial thickness burn goes deeper into the dermis from the epidermis. These can present with blisters, deep, dark redness to whiteness. These burns are very painful, because the dermis is thick with sensory (or afferent) nerve endings that like to tell the brain how much pain they are in.

A third degree, or full thickness burn goes through epidermis, dermis, and subcutaneous layer. These tend to be dark brown in color and leathery in appearance. Essentially, the proteins in the skin have been denatured, which is the same thing that happens to an egg when it goes from liquid to solid when you fry it. These burns tend not to hurt because the nerve endings that tell the brain that there is pain have been destroyed. However, you don’t see a third degree burn without a big old ring of second degree burn wrapping around it, so these patients will still be in pain.

There is a tool we use to determine the total body surface area (TBSA) of the burn called the Rule of Nines, that helps drive treatment priority and planning. Below is a graphic showing how you apply the rules to body areas (Source:http://armymedical.tpub.com/MD0576/MD05760056.htm): ruleNines
ruleNinesBody

Once you calculate the percent of body area burned, here is a suggested treatment priority:

burnPriority

“GCS” stands for Glasgow Coma Scale, which is a more detailed AVPU diagnostic tool that you should definitely check out.

Any patients that are yellow or red priorities are going to be in immense pain (so can a green, but we’re talking life threats here). As a paramedic, we are limited to how much morphine we can give a patient based on protocols and what’s on the truck. With MD approval, we can give more. It is not uncommon for an MD to load you up with lots of extra morphine when you are transporting a severe burn patient to a burn center. Be prepared to deal with a patient who is screaming out for help.

Other things to be on the lookout for with burn patients is what we call a “fluid shift” where the body moves fluid from the rest of the body to the burned areas as part of the inflammation response mechanism. It is important to begin fluid resuscitation immediately with burn patients, as this shift can cause hypovolemic shock. Use the Parkland Burn Formula to calculate how much fluid you give to your patient.

4cc fluid x patient’s weight in kg x %TBSA

Key detail, when using %TBSA, DO NOT move the decimal point over two places to the left. If your patient weighs 150kg and is burned on 10% of his BSA, then the calculation is:

4cc x 150kg x 10 = 6000cc

As you can see, this is a lot of fluid. You want to give your patient 3000cc of fluid in the first eight hours of treatment, and 3000cc more of fluid over the second 16 hours of treatment, so it’s 6000cc over 24 hours.

Lactated Ringer’s is the preferred fluid because it can help with the activation of white blood cells called neutrophils, which help in fighting infection. It is also turned into an alkaline buffer by the liver, which helps with metabolic acidosis that may be occurring from the burn injury. There are other things it can do which are a little more advanced for this discussion, so let’s just keep it at “preferred.” Normal saline is fine, too, just remember is pH and temperature when treating a patient that is at risk for shock.

Paradoxically, you need to watch for hypothermia with burn patients and cover them with clean, dry dressings / sheets. It’s that shock thing again.

Ultimately, what will help a severe burn patient is debridement (removal) of the dead tissue and new skin. There are hug risks for infection with severe burn patients, so broad spectrum antibiotics are probably something that will be used.

This is another injury type that when things are primitive or near-primitive in terms of medical care, the prognoses aren’t too good.

The best thing I can recommend is that an ounce of prevention is worth a pound of cure. Stay away from fire, people throwing fire, people shooting fire, and things that like to catch on fire. To that end, hydrocarbons like to burn. Octane, which helps make up gasoline, has a chemical formula of C8H18. Methane, the simplest hydrocarbon, has a chemical formula of CH4. That kick-ass polypropylene underlayer you’re wearing has a chemical formula of C3H6. Notice some similarities? That warm layer is woven gasoline, and it can’t wait to catch on fire, stick to you, and melt your skin off. Polyester in your wicking shirts for warm weather have some carbon and hydrogen in them too, and tend to like to burn, so keep that in mind.

Be sure to shop around for Nomex gear and other fire-resistant fabrics. Cotton and wool work well too, and there are some sites out there that have how-to’s on making your cotton a little more fire resistant using Borax and whatnot. Use your own search engine and find what you need. Remember, I’m just a guy on the Internet, and if you follow my advice and burn yourself to death, that’s on you.

In closing

From a perspective of a Bolshevik flying monkey takeover and breakdown in rule of law, supply chains, and other things that keep civilization civil, this was again designed to scratch the surface and get you thinking about what kind of injuries one might see when people start hurling kinetic and thermal weapons at each other. If you have a crew you train with, I hope this helps facilitate some discussion to help you expand your medical training and increase your medical knowledge.

Part V is going to hit some gear ideas.

#EarthDay is Serf Day

USSR-flag

Ignore the guilt-tripping hokum being spewed by the most hypocritical, consumptive members of the chattering, parasitic class.

Earth Day is collectivism wrapped in aqua blue and sea foam green wrapping paper. It denigrates the individual as incapable of making decisions in his own self-interest to keep his water drinkable, his air breathable, and his food nutritious without strict management at the force of a gun by unaccountable bureaucrats from distant capitals the world over.

Never forget that the USSR was horribly inefficient with its natural resources, and single party-ruled China’s “economic miracle” has been made possible by them poisoning their own country and people to allow their factories to churn out plastic doo-dads en masse for the world to enjoy and then throw away.

Thomas Friedman, Al Gore, and many of the other loudmouth beneficiaries of centralized globalism can be thanked for this state of affairs.

On this day, be sure to ignore a diktat from some alphabet agency pinhead, or some guilt-ridden proclamation from some corporate / government money-addicted NGO busybody intent on stripping away your freedom and the freedom of the next several generations simply for liking something they do not want you to like, and living without their input into your lives.

You know how to take care of your surroundings and yourselves. Don’t let any person tell you otherwise.

 

Don’t be a serf.

sat-cong

Jim Kunstler, you have a way with words

Pure magic from this Monday’s latest:

The USA is exhibiting pretty severe signs of that sclerosis in the demented behavior of its leaders in episodes such as the current unnecessary manufactured fiasco over Ukraine to the physical deterioration of our towns, roads, bridges, and all the plastic crap we managed to smear over the mutilated landscape to the comportment of our demoralized, mentally inert, drugged-up, tattoo-bedizened populace of twerking slobs.

In short, it is self-evident that Russians have an abiding interest in the Crimea and we have none, while both the material and cultural life of the US is in a shambles and much more worthy of our own attention.

Brilliant. Thank you for the ironic chuckle from hell.

‘Murica.

Bleg on binoculars

Looking for recommendations compact binoculars for field use.

Requirements:

  • Durable
  • Idiot-resistant
  • Able to fit in a 1qt canteen or similar sized pouch on a plate carrier or LBE

That’s pretty much it. Not looking to get my pants pulled down over the price, but I don’t want junk either. A four figure pair is probably too much.

Thanks for any help.

Let’s talk trauma part III: Treatment philosophy and things to think about in a SHTF/WROL setting

MSM-DKH-patch
Photo: Mil Spec Monkey

Part I: Physiology and pathophysiology of shock
Part II: Triage, treatment, and the rapid trauma assessment

Today’s installment is going to be a little more general information dealing with treatment philosophy, thinking through a SHTF medical system, and some training considerations.

DO NO HARM

I admit that I am a geardo of the highest order. I love gear. I love fucking around with gear. I love learning new skills that require more gear. However, mastery of gear is always secondary to mastery of knowledge and skill, because that’s where it matters most and where the satisfaction happens.

In medicine of all kinds, we are looking for physiological outcomes that are good for the patient. We are not looking to fill out a scorecard on use of cool-guy devices. Always be thinking about what is going to help your patient the most without introducing unnecessary risks. Yes, it’s cool to decompress a chest. Yes, the CAT-T is some badass kit. Make sure you know the benefits AND risks of each treatment option and weigh them. You’re not doing this to play with shit. You’re doing this to help people. The patient’s outcome has to be your top priority once you and your scene are safe to do work.

When I see all of the cool-guy gear people are putting in the IFAKs, I am happy that they are learning about medical treatment options, and I seriously hope they took the time to learn basic anatomy, physiology, and the pathophysiologies of the things they are going to treat with the cool-guy gear. Because someone has a chest wound does not mean you automatically stab them with your 14-gauge needle at the second intercostal space to treat for a tension pneumothorax. You need to be sure you know how to differentiate between a simple pneumothorax and a tension pneumothorax, and the signs and symptoms of each that will guide your treatment. Make sure you understand all of the BASIC things you can do FIRST to manage that patient, before he gets to a tension pneumo. Don’t just use the tools, know WHY you use them, WHEN to use them, and WHEN NOT to use them.
Software > hardware.

The Hippocratic Oath applies whether you are a liberty-minded trauma surgeon that’s the medical director of a resistance cell, or a partisan with basic first aid training in the field treating a child’s broken finger. DO NO HARM. Do the best thing for your patient by starting basic and working towards advanced treatments based on solid assessment, knowledge, and skill.

The SHTF medical system

I like to cite the Boston Marathon Bombing as a great example of a response to a MCI with seriously bad traumatic injuries. Three people died on scene, and that was the ONLY place people died because of the bombs, because there were enough people on scene who knew enough about basic first aid and treating for shock that stabilized people almost immediately. It helped that you were in a big city like Boston, that not only has a bunch of colleges, but colleges with medical schools and lots of hospitals to boot. What you saw with that attack was rapid response with BASIC first aid; stopping bleeding, giving oxygen, keeping patients warm, and treating for shock, combined with the ability to move patients off scene quickly to definitive care at ERs and ORs across the region. That was a day that everyone who helped others should be proud of. A lot of lives were saved.

In a SHTF/WROL situation where societal stability has been compromised and Bolshevik flying monkeys are hovering around hospitals to see who shows up decked out in Multicam with mysterious GSWs, fragmentation, and burn injuries, it’s not going to be as clean as the medical system in Boston, but you need to be thinking with your friends and fellow travelers what your micro medical system looks like. Just like many other aspects of preparedness and prepping, medical is no different. The man that is an island will die alone in a pile of silver coins and IFAKs. The man that is a node in a network that can rally quickly to meet contingencies stands a damn better chance because he has enhanced skills, people to work with, and places to take people for better patient care.

Your system will extend as far out in the field as skills, infrastructure, and materials allow, and definitive care will be as close for the same reasons.

Specialty centers – or the lack thereof. Medical systems have tiered systems to rate hospitals to treat trauma. A Level I designation means you have general surgeons ready to go 24/7. You have specialists like neurosurgeons, vascular surgeons, maxillofacial surgeons, plastic surgeons, etc., that can get mobilized in short order. Most of these hospitals are located in major metropolitan areas and are the places that all of the other hospitals in the area send their most serious trauma patients. At the other end of the scale, you have Level V trauma centers that “provide initial evaluation, stabilization and diagnostic capabilities and prepare patients for transfer to higher levels of care” – IE the Level I or Level II trauma centers. They’ll work to stabilize you for transport, but you are not going to get your serious trauma fixed there. Burn centers are even more sparse and tend to be located around major university systems. If you find yourself out in Indian Country, chances are your access to these centers will be slim to none. So the question is, how do you push as much of that advanced care into the field as safely and effectively as possible? What do you do if you know your access to these specialty centers will be nil? I’ve worked days where bad weather alone grounded everything that flew and kept ground vehicles from making the trip into the metro specialty center. If you were having a heart attack, lots of luck. People will do the best they can at the community hospital, because nobody is going to the cardiac cath lab today.

See this? Yeah. You most likely won’t get this when there’s a mushroom cloud over the metro area.

Electricity – or the lack of it – has an enormous impact on medical care today. It drives it. Go to any hospital and look around. Patient telemetry, IV pumps, refrigeration, labs, lighting, medical gas systems, dispensaries, endoscopic tools, MRIs, CT scanners, X-ray machines, computers, you-name-it, all run on electricity. In a pre-hospital setting, one of the most critical tools we carry is the cardiac monitor / defibrillator. It provides gobs of information besides heart rate and rhythm and it eats up batteries like no tomorrow. Without it, we are much less able to diagnose and treat some of the most serious medical problems we encounter. What will medical care look like without electricity? What happens when the fuels that run the backup generators go out? Do you plan a SHTF system to NOT have electricity as a prerequisite? Can you develop a mobile microgrid for basic infrastructure? What about man-portable power?

Portable solar generation is an option. Highly visible, but an option.

Man-portable renewable power.
Source: http://www.bourneenergy.com

Transport – or the lack of it. A great trauma system has a great transport system in place. Sea, air, and land transport are ubiquitous. These transport systems require skilled pilots, drivers, and in-vehicle medical personnel. Every vehicle is a complex, fuel-sucking monstrosity full of medical equipment that requires electricity. Fleet costs on these things are astronomical. What do you do when your transport capability is an ATV running off siphoned gas? Where are you going? How many can you take? If you can’t get to a specialty center, can you get to a mobile surgery center? A base camp? Transport is no longer ubiquitous, it is a luxury.

Every flat surface on this Jeep is being used to transport wounded. Always be thinking through how you mod your gear to fill this role.

If you’re lucky, you MIGHT have the Road Warrior helo for air transport.

Drugs, medications, blood, hospital supplies. You’re going to need them, and this is a sticky one. Each individual that takes a prescription needs to have a contingency supply lined up and needs to have it as part of his kit. He also must have a contingency plan for when the beta-blockers, insulin, and a nitroglycerin run out. What is your ability to contribute after that and how much does your life expectancy change? The best medication ever invented for half of the maladies that we live with today is sweat. Hope you are working on your PT and diet!

At the system level, how do you outfit your teams with drugs and meds for the field? Pain meds are highly controlled and need to be supplied in ways that keep minimally-trained personnel from killing each other from overdoses or allergic reactions. How do you stock a supply for your mobile OR / ER?

Antibiotics, antiseptics, and all the things that kill the creepy-crawlies that want to crawl inside of you and your team and kill you. Again, how do you bifurcate the supply between field people with basic training and advanced providers further up the chain?

Blood and blood products are the best tools to treat for blood loss, yet they require a major logistics chain and training to use them. Fresh frozen plasma, packed red blood cells, and straight up blood all require refrigeration and intense inventory controls.

There are general anesthetics, local anesthetics, induction agents, paralytics, and all sorts of high-speed anesthesia needed to perform surgeries.

There are sutures, staples, screws, rods, OR tools, splints, drains, and all the other stuff used to bolt someone back together.

There’s the basic hospital gear from gloves to linens to masks, IV bags, IV drop sets, syringes, needles, O2 masks, saline, Lactated Ringer’s, you name it.

The logistics question is a huge, nasty one, because you also need funds to acquire these things, unless people get very, very creative. There is no easy answer.

The uncomfortable question

If the SHTF, can you count on access to any form of your current medical system or will the mandarins at the top of it who are addicted to Medicare, Medicaid, and now ACA payouts going to ensure that the Bolshevik evil flying monkeys can keep their political foes from getting treatment should they need it?

Healthcare lobbying. Think they are for or against the ACA?  Source: http://www.opensecrets.org/industries/

Healthcare lobbying. Think they are for or against the ACA?
Source: http://www.opensecrets.org/industries/

Unless your town or established medical system doesn’t play ball with Team Tyranny and you have a couple of regional hospitals that are still online, your SHTF medical system is going to go back at least 100 years in treatment capabilities. The reality is, even with getting great on-scene care with trauma, the lack of adequate definitive trauma care a short transport away means that mortality rates are going to go through the roof. You’d better learn how to supply comfort measures as well as life-saving techniques.

There are guys who have decades of experience in unconventional warfare that have lots of good things to say about the development of the auxiliary that have tight application to SHTF/WROL at home. I’m no expert and just going by things I’ve read over the years. John Mosby at the Mountain Guerrilla has a great piece on it. Check it out.

The points I make here are to spur thought on the development and sustainment of the medical portion of the auxiliary. Personally, I think the docs and advanced practitioners that are telling insurance companies and the .gov to shove their payment plans up their asses and taking cash-only customers are fertile ground for recruiting by liberty-oriented thinkers. It’s free market thinking after all. The only people I know that have Class III autos all seem to have “MD” as a suffix to their names. My knowledge of the paramedic corps is that it is one of the most heavily-armed segments of society per capita, and is used to seeing shitty stuff happen all day long, so it is a natural fit for the medical auxiliary if not outright medics at the squad level. It’s an interesting stew from which to draw from, no?

Training – going from individual to team

Great medical care is a team effort. From first medical contact in the field to the guy that wheels you out of the hospital after a successful outcome, a good medical system understands that treatment is a chain of events involving many specialties and people. To that end, the field guys all work off a standard set of protocols that conform to a national standard, or tactics, techniques, and procedures (TTPs) for the .mil dudes, that are developed by an MD or team of MDs for the field guys to use. These make sure that everyone that shows up on scene understands each other, assesses with the same methodology, and performs skills in a similar way.

I have been on scene at an MCI where citizens, fire, EMS, law, and military people from all over the continental US were all thrown into the fray unexpectedly and worked together beautifully because our bases of knowledge and skill were essentially the same when it came to field treatment.

So if you are a guy with a boss IFAK that’s watched some videos of chest decompressions and use of a nasopharyngeal airway adjunct, that’s an excellent start. Do you know the priorities in assessing a patient from head to toe and what to look for if he yells, “I can’t walk!” and drops to the ground? Do you know how to splint a broken arm? Do you know how to ventilate a patient and watch for increased intrathoracic pressure? What if you are in a 12-man squad where three go down and you and two others are ordered by your squad leader to triage and treat? Do you know what to do?

I’m not asking these things as some sort of dick-measuring challenge. I’m bringing these up because if little groups of partisans (LGOPs – apologies to the paratroopers!) are running around killing bad Bolshevik flying monkeys in an absence or orders and people need medical care, it’s going to help to have some common approaches to how it gets done. When people get hurt and it’s a chaotic shit-show, you need every little thing there is to mitigate the chaos, and common training helps.

So here’s one very strong suggestion. Go get your EMT-Basic certification. Seriously. They offer courses at community colleges (that you’re already paying for through taxes) everywhere. It’s not too bad on the wallet, either. You may have to sacrifice a couple of evenings a week and a Saturday every now and then over about a four to six month period but you will learn the basis that is Combat Lifesaver, TCCC, paramedicine, and START mass casualty protocols. You WILL have fun. You WILL expand your network. As I have mentioned, I have yet to meet a medic or EMT that isn’t armed to the teeth and prepared for the end of the world. You meet some cool people in those classes. I was lucky enough to meet a retired 18B and a 13B in my basic course and we have been friends ever since. We also had a general practice MD who was taking it for shits and giggles and she was a great resource for everyone helping with assessments. I’ve made my case with this, but think about it. It’s worth it. If you can also jump on with a volunteer fire department after you get your cert, you can get some great experience.

These guys approve.

These guys approve.

Switching gears. Let’s talk about your team, where life is imperfect and you are doing what you can with what you have. You and your buddies sure as shit ain’t the 75th Ranger Regiment at best and you might be the local shuffleboard club at the worst. Bill has high blood pressure, Bob is allergic to bee stings and morphine, Fred has asthma, John’s lower back and legs go numb by noon every day and he has a sulfa drug allergy, and Carl’s knees were turned into dust back in ’89 in Panama.

Let’s say the Bolshevik evil flying monkeys have surrounded the community hospital and are forcing the rationing of care and isolating medical staff based on known political affiliations. Your leaders have run the hospital through a CARVER matrix and decided that it’s time to return its control to the locals. To that end, you and the men mentioned above have been tasked with zone and route reconnaissance of the hospital and flying monkey force, and have 48 hours to hump it to the hospital, observe, collect information, and return with info fulfilling the commander’s critical information requirements. It’s a four hour slog each way through deciduous forest into a exurban area of strip malls, busy streets in the daytime, and population with a proclivity to give the middle finger to being micro-managed by bureaucrats from a distant “capital city” that has no connection to the local community. You’re in the southernmost section of the Appalachian redoubt and it’s mid July; hot, humid, and nasty. You’ll be moving at night to avoid detection and hunkered down in observation points during daylight hours. If you get detected, there ain’t no cavalry coming. You fight your way home, die in place, or surrender and find out what waterboarding is all about before you have an “accident” while in custody of the Bolshevik flying monkeys.

The lightest load carried by your team is 35 pounds and the heaviest load is 65 pounds. Let your imagination run wild for a few minutes. Now let’s break this down to two scenarios:

  • Scenario one: We are all special snowflakes, never trained medical together and only have surface knowledge of our teammates medical histories. Bob gets stung by a bee one hour in and goes into anaphylaxis almost immediately. He fumbles around his IFAK and pulls out some kind of pen thing and passes out. You don’t know what it is, so you have to take the time to read it and figure out that it is an Epi-Pen, which contains epinephrine, which is a nuclear-grade drug that constricts the blood vessels, dilates the bronchial pathways, and puts your heart into overdrive. It’s great for treating anaphylaxis as well as cardiac arrest. Remember the scene in Pulp Fiction where Mia Wallace gets a syringe full of “adrenaline” straight to the heart? Same shit. But I digress. So Bob has now turned blue and three minutes have gone by. His brain is now turning into mush because of a lack of oxygen from a tongue that has swollen to the size of a softball and an upper airway that has welded itself shut. His capillary beds are starting to weep out all sorts of nasty fluids, and Bob is circling the drain. You finally jab Bob in the thigh with the Epi-Pen, but it’s too late. Bob rallies back a little bit and you are able to discern that he has the mental ability of a potato. So you are now stuck with a teammate essentially dead but still breathing, the mission clock is ticking, and you have lost 25% of your team before you have even done anything. What do you do now?

This guy. Don’t be him.

  • Scenario two: We are all special snowflakes that have made our relevant medical histories known to our cell since life is imperfect and we work with what we have. You talk to Bob and decide that the risk profile of the mission is incompatible with his medical history. It’s summer in southern Appalachia and you will be stomping through the woods, laying on the ground, and will be far away from any backup. There will be stinging and biting creatures of the insect and animal variety everywhere. You go to your chain of command and discuss the situation, and they are able to swap a guy from another team that has no bee allergies. Furthermore, you know that Fred’s asthma is only triggered by cold weather, and Bill’s, John’s and Carl’s maladies are manageable for this little jaunt. Your cell has a great PT and yoga (yeah, yoga. Problem?) regimen and people have trained up their bodies for this work. John has pieces of 90mph tape with “SULFA ALLERGY” written on them taped on his IFAK and plate carrier. Each one of you has done the same with your blood types, just in case. Fred carries three rescue inhalers and some a corticosteroid vial, syringe, needle, and saline flushes in his IFAK, just in case. He tells you where to find them, what they do, and how to use them, in the very remote chance something sets off his asthma. You guys have practiced getting venous access on each other and know how to set up IV PRN adapters. Each team member’s IFAK carries the same gear and you all have been trained how to use the contents. You do the mission and the intel is on the money. The hospital is back in local hands by the end of the week.

Make sense? I hope it does.

When it comes down to training, get your people together and create scenarios that resemble what you might encounter. When you are doing assessments, ESPECIALLY the trauma assessments, GET YOUR HANDS ON EACH OTHER.

Really do the work. You need to know what normal feels like a hundred times over so it’s easier notice abnormal when it presents itself. You don’t necessarily have to strip each other naked, but you do need to throw some modesty and apprehension out the window and do the assessment well. The more you do it in training, the better you’ll be when doing it for real.

Realistic scenarios and training are great things.

Get to know each other and think through what you need to do to keep your group healthy and functioning. Think beyond the IFAK.

In Part IV, we’ll look at some types of injuries that are most likely to occur in a bullets-flying SHTF/WROL scenario.

In Part V, we’ll get all gear queer and talk medical equipment.

Let’s talk trauma, part II: Triage, treatment, and the rapid trauma assessment

boston-marathon-lives-saved-jpeg-800x600

Part I: Physiology and pathophysiology of shock

This is the next installment on a series to help people in a SHTF/WROL situation deal with the types of traumatic injuries and concerns they may encounter. The focus is on making the best out of what you have and keeping people alive. Today we’ll focus on triage, treatment, the rapid trauma assessment, and general guidelines to “find it / fix it.”

Triage and treatment

Trauma is a surgical disease. The goal for any trauma patient is to get him, when necessary, into the operating room in 60 minutes or less from the time of injury. This is called “The Golden Hour” and it is the standard that most EMS systems aim for. In a trauma scenario, a patient’s mortality rate goes through the roof if it takes more than 60 minutes to get them under the knife.

This is where I mix it up a little between civilian triage and treatment, and military triage and treatment from Tactical Combat Casualty Care (TCCC).  The table below goes over the key differences and treatment protocols with judicious paraphrasing.

Civilian Mass Casualty Incident (MCI) TCCC[i]
Goal: Get the most critical patients off the scene as fast as possible and into the OR / definitive care. Goals: Fight the bastards. Make them stop trying to kill you by killing all of them or by making them go away. Keep as many people in the fight as you can. Stop major bleeding. Self-treatment as able. Administer more advanced care after the fight is over. Try not to get the medic killed.
Triage priority: Triage priority:
Red – Immediate. Unable to walk, does not obey commands, respirations > 30, capillary refill > 2 seconds. Stabilize fast, load and go emergency traffic to trauma centers. Immediate – Rapid intervention to save life, limb, or eyesight.
Yellow – Delayed. Unable to walk, obeys commands. Implies perfusion is adequate enough that mental status is maintained. Stabilize on-scene. Next priority for transport. Delayed – Significant injury. Requires stabilization, but PT will not deteriorate for several hours.
Green – Minor. Walking. Minimal – PT is injured but will remain stable for at least 24 hours. Can supply self-aid and buddy-aid.
Black – Expectant. Unable to breathe on their own. PT is dying or dead. Expectant – Injuries incompatible with life. Major treatment withheld until higher-priority PTs cared for. Provide comfort measures as able.
Treatment priority: Stages of care:
A – Airway: patent? Care Under Fire: Fight still going on. Main priority is to stay in the fight. Stop major bleeding as able. Firepower comes first.
B – Breathing: adequate? Tactical Field Care: Fight’s over. Treat with medical equipment on scene.
C – Circulation: adequate? Capillary refill < 2 seconds? Peripheral pulses? Rate? Combat Casualty Evacuation (CASEVAC): Treatment rendered once patient is on board air, ground, or water transport. May be treated at medical personnel staging areas.
D – Disability: What is the patient’s mental status? Alert? Responsive to Verbal stimuli? Responsive to Painful stimuli? Unresponsive? Treatment priority:
E – Expose: Cut clothes off and conduct the rapid trauma assessment C – Circulation: Stop major bleeding with tourniquets, etc. (This is primarily in the Care Under Fire stage).
Ops A – Airway: patent?
Red, yellow, and green treatment areas (CCPs) will be identified by tarps of the same color placed on the ground. The treatment section chief coordinates with the transport section chief to get patients cataloged, loaded and transported to the right hospitals via air, land, and/or sea. B – Breathing: adequate?
C – Circulation: adequate? Capillary refill < 2 seconds? Peripheral pulses? Rate?
D – Disability: What is the patient’s mental status? Alert? Responsive to Verbal stimuli? Responsive to Painful stimuli? Unresponsive?
E – Expose: Cut clothes off and conduct the rapid trauma assessment
[i] Casey Bond, MPAS, PA-C, Combat Medic Field Reference (Jones and Bartlett Publishers 2005) 1-3

Here’s the START triage algorithm for adults in a civilian MCI:

StartAdultTriageAlgorithm

Below is an EXCELLENT visual of a civilian casualty collection point (CCP) from the LAX shooting in November, 2013. The tarps are the treatment areas for patients based on the above flowchart. Ambulance Drivers are ready to drink coffee and cruise to the hospital. ‘Cause that’s what we do.

Think about how you might set something like this up for yourselves in a SHTF situation.

The rapid trauma assessment

No matter what situation you find yourself in, this assessment is critical. Trauma is all about finding life threats and fixing them immediately. The rapid trauma assessment is designed to do just that. This will follow the civilian model. In a TCCC mode, find bleeds first.

We are looking for deformities, contusions, abrasions, penetrations / punctures, burns, tenderness, lacerations, and swelling in our patient. The mnemonic for this is DCAP-BTLS. If you ever say to a medic “I’m looking for DCAP-BTLS” you better know what they stand for or you will be doing pushups.

Before we go into it, let’s talk about bleeds.

  • Arterial bleed: Bright red (oxygenated) blood and lots of it pulsing out in streams. If you see this, you better haul ass and get the bleeding stopped
  • Venous bleed: Dark red (deoxygenated) blood and lots of it oozing out rapidly depending on the site of the wound. Not a great sign. Haul ass on this one too.
  • Capillary bleed: Bright red blood slowly oozing out from a wound. This is not life threatening. Not a big deal. No need to do anything right away.

If you have time, get some nitrile gloves and some eye pro on, because it’s going to get messy.

Look at the patient. Is he breathing? If not, do a head tilt, chin lift airway maneuver. Does he start breathing on his own? If yes, this patient is an immediate triage and treatment priority. If no, he’s dead. Move on to other patients and reassess this guy later.

What is his mentation at this stage? Conscious, alert, and obeying commands? Conscious and alert, but mumbling and reciting multiplication tables? Barely awake? Knocked the fuck out? Whatever it is, make note of it. A patient’s mental status is a key indicator of his level of perfusion and his priority. The mnemonic here is AVPU, which stands for:

  • Alert: Patient is awake and alert. They may or may not be making sense, and may or may not be following your commands. Be watchful if they start slip-sliding down the scale.
  • Verbal Stimuli: The patient responds to verbal stimulation. Chances are their eyes are closed and they open when you call their name. Same thing applies in making sense and following commands as above. The less they do, the worse they may be.
  • Painful stimuli: The patient responds to painful stimulation. A rub on the sternum with your knuckles. Pinching their fingernail bed between your finger and a pen. Note how they respond. Do they localize the pain and grab at where you are stimulating? Do they have a general response that is non-specific? The difference is a key distinction between levels of brain injury. The less specific the response, the worse they are.
  • Unresponsive: Exactly what it means. This is where it is important to gauge the patient’s ability to breathe on his own in a MCI or Care Under Fire situation. It he cannot breathe on his own, he is Expectant. Move on to other patients. If he is breathing on his own, he is Immediate. Treat accordingly.

Check the airway – is it open / patent? If not, stop the assessment and get it open with a head-tilt chin-lift, or if cervical spine injury is suspected, a modified jaw-thrust maneuver. We’ll talk about some more advanced airway stuff further on down the way. The key here is to make sure the guy can move air. The modified jaw thrust is a bitch of a move and you will burn out your fingers keeping tension on the patient’s jaw. Be prepared to switch people out or start thinking about an advanced airway, since having to do this maneuver implies that his airway is compromised.

Check the breathing – is it adequate? If it’s < 8 or > 30 respirations per minute, assist ventilations with a BVM and 15LPM 100% O2 if you have it. Your ventilations should be 12-20 a minute, with an emphasis on 12. All you are looking for is chest rise and fall for each ventilation given. You do NOT need to empty the entire contents of the BVM into your patient’s lungs.

Bag valve mask. Get one if you don’t have one already.

Note the resistance – or compliance – when ventilating. If there is a lot of resistance, there could be a pneumothorax, or an intrathoracic bleed that’s increasing intrathoracic pressure, or some other kind of really bad thing. A helper for pacing your ventilations is to say “BREATHE one thousand, two one thousand, three one thousand, four one thousand, five one thousand, BREATHE one thousand, two one thousand, three one thousand, four one thousand, five one thousand” and squeeze the BVM slowly over “BREATHE one thousand.” That gets you about 12 ventilations a minute. Chances are you’re going to be excited, so work hard at not counting too fast.

Check radial – i.e. wrist – pulses, BOTH OF THEM at the same time. If they are present, then your patient has a systolic BP of at least 80mmHg. Note the pulse rate. Your count doesn’t have to be perfect. At this point “Wow, that’s fucking fast” or “Seems normal” is adequate for quantifying pulse rate. If no radial pulses are present, go to the carotid artery in the neck. If you feel a pulse, the patient’s systolic pressure is at least 60mmHg, and you are in really deep shit. Chances are his heart rate will be high because he’s in compensated shock. If you feel barely any to no carotid pulse, chances are this guy is expectant and hopefully you were able to ask him if there was anything he wanted to say to his wife before he died.

A good medic or EMT can do almost all of this at once if the patient is conscious. Have a conversation with the patient while you are feeling his radial pulses. If pulses are present, he can converse normally and speak in full sentences, then you know you have a good airway, adequate breathing, and good circulation. If any of those basic things are off, you know something is up and you need to be highly alert.

ALWAYS use your patient as a diagnostic tool. He’s going to provide you great info about his status. Ask him what hurts, if he has numbness or tingling anywhere, if he lost consciousness, ask his name, his birth date, the day of the week, his current location, and finally ask him to wiggle his fingers and toes. With that, you’ve just done a field expedient neurological exam and can check off AVPU. Note any deficits. PS: I always ask who the President of the United States is. Around here, that wakes them right up. It always come with great editorial comments.

Continue the assessment by doing a blood sweep by running your hands down the patient’s head, torso, and legs. After each major area, check your gloves. If you see blood, stop and assess the wound. Cut away anything that gets in your way. If it is a life threatening bleed, stop the assessment and control the bleeding with direct pressure, a hemostatic agent (CELOX, QuickClot, etc.) and/or a tourniquet. DON’T use hemostatic agents on any wounds outside of the extremities. Continue the blood sweep. If no other bleeding is found, continue on. One thing, the blood sweep should be fast, like 5-10 seconds fast.

CONGRATULATIONS. You have completed the rapid trauma assessment. You now know your patient’s mental status, airway status, breathing status, and circulatory status. You can now form your treatment priority for this patient. If you are getting this done in under three minutes, you are doing great. Get your patient to the casualty collection point (CCP) and start treatment. Get your IVs and fluid resuscitation going as indicated.

Next we’re going to do a more detailed assessment if we have the time and the patient is stable enough. The analog to this in TCCC would be the Tactical Field Care phase. We want to get a better – still rapid – look at the patient and find more things to fix if they are life threats. Key point here – TAKE HIS CLOTHES OFF. Seriously. If you can’t see it, you can’t find it, and you won’t fix it. I usually keep my patient’s underoos on if they are 100% conscious, alert, and oriented and inspect “down there” with their permission after a description of what I need to look for and why. If their mentation is altered, the underoos are coming off so I can check the genitalia and rectum for bleeding if there is any thoracic /abdominal trauma or pain in any area that indicates thoracic /abdominal injury.

Head, eyes, ears, nose, and throat (HEENT)

Start at the head and work your way down. Inspect and palpate – which means feel around in vulgar terms – the head and neck. Remember the DCAP-BTLS mnemonic. Key to look out for is fluid coming out of the ears or nose, as it could be cerebral spinal fluid, which indicates a skull fracture of some kind or disruption of the blood / brain barrier. If you see it, dab it with a gauze 2×2 or 4×4. If it looks like a pink blood spot with a halo around it, that’s CSF.

CSF on gauze. Notice the halo.
Source: http://medicinexplained.blogspot.com/2011/12/csf-rhinorrhea-double-ring-sign-ring.html

If you feel bones grinding around – known as crepitus – this is bad, too, as it also indicates skull fracture. Check the pupils and eyeballs. Are they equal, round, and responsive to light? Great. If one or both are dilated and your patient has an altered mental status, you are in deep shit because your patient probably has a bleed going in his brain. If you are out in the middle of nowhere without rapid evac to an OR, this is most likely fatal.

Look for anything in the mouth that can result in an airway threat and take steps to mitigate. Teeth, Copenhagen, soft tissue, etc. The tongue is the most common airway obstruction, and if you hear snoring noises from your patient, most likely his tongue is in the back of his throat. Try basic airway maneuvers to open the airway like the head-tilt chin lift or modified jaw thrust first, and an oropharyngeal airway (OPA) adjunct if the patient has no gag reflex, and a nasopharyngeal airway adjunct (NPA) if he does have a gag reflex. Here’s a nice instructional video for measuring and placing OPAs and NPAs.

  If cervical spine injury is suspected, stabilize c-spine and apply a c-collar if available. Inspect and palpate the back of the neck for crepitus or deformity before applying the c-collar. If you don’t have one, use a SAM splint, towels, clothing, and tape to create a hasty c-collar. The goal is to prevent the head from moving around and exacerbating a cervical vertebrae fracture that could slice into the spinal cord. Make sure you’re not restricting circulation in the neck or breathing with the hasty c-collar.

Improvised c-collar. Dig it.
Source: http://www.trailspace.com/forums/trip-reports/topics/130492.html

Neck

Inspect and palpate the neck. Look for any bruising or open wounds on the neck. If there is a wound near the jugular vein or carotid artery, apply an occlusive dressing like Vaseline gauze, or plastic wrap (a section of MRE rapper, etc.) to prevent air from going into the wound and causing an air embolus in the circulatory system. You may need to position the patient on his left side to mitigate the air embolus from entering the heart. Keep c-spine precautions in place if you do.

If the jugular veins are distended (bulging out), this could be a sign of circulatory compromise, with the right side of the heart failing to move blood adequately. This could be from a pericardial tamponade, which can only be fixed in the hospital, a tension pneumothorax or even a severe hemothorax.

Jugular venous distension. Never fun to see in trauma.
Source: http://commons.wikimedia.org/wiki/File:Jugular_Venous_Distention_%28JVD%29.JPG

If the patient’s windpipe – i.e. trachea – is deviating to one side, this is an ominous sign of a late stage tension pneumothorax, also known as a collapsed lung.

Tracheal deviation in a tension pneumothorax.
Source: http://blog.tacmedsolutions.com/?p=86

You may need to needle decompress the affected lung, but you’ll need to assess the chest to make the call.

Chest

Check the upper chest for little bumps. If you can push down on them and they pop like Rice Krispies, this is probably subcutaneous emphysema, and is a sign that the patient’s  airway has been compromised. The larynx, trachea or bronchi may have been damaged and air leaking air into the chest cavity. Look for this sign in pneumothorax as well. Personally, I have never seen this in the field, so who knows what it’s really like.

The other critical findings for a tension pneumo are low blood pressure, tachycardia (pulse > 100 bpm), a narrow pulse pressure (this is the difference between the systolic and diastolic pressures. A normal pulse pressure is 120/80. A narrow pulse pressure with hypotension is 70/60), absent lung sounds on the affected side, fast, shallow breathing, and low O2 saturation. The trachea will deviate AWAY from the side of the collapsed lung. NOTE: Tracheal deviation is a LATE sign in a tension pneumo. Look for the other signs and symptoms first. If you wait for tracheal deviation to show up, you’ve probably killed your patient.

You’ll need a 3.25” 14 gauge need and catheter for decompression. Insert the needle in the second intercostal space just above the third rib at the midclavicular line (in line with the middle of the collar bone) of the affected side. Press hard and remove the needle, and if you do it correctly, you’ll hear a flood of air come out of the catheter. Create a flutter valve with a spare glove fingertip and place it over the top of the catheter. Some of the newer catheters have a one-way valve built in, so what you have already may be adequate.

The 3.25″ needle is preferred, because most likely your tribe is full of studmuffins with 50″ chests who all bench 550lbs easily. The other guys have all the fat dudes with man tits. In either case, that’s a lot of material between the skin and the chest cavity full of air. The shorter needles may not make it all the way through, so keep that in mind.

Press on the clavicles for crepitus. If it is present, note it but keep going. Unless the clavicle is so screwed up that it looks like it is stabbing the the lungs, or you see sign of massive hemorrhage from a nick of subclavian artery and/or vein, it is probably not a life threat.

Press down on the ribs and feel for crepitus. Notice the patient’s work of breathing. Are both sides of his chest rising and falling in unison? That’s good. If you feel crepitus and see a portion of the ribs moving collapsing while the rest of the ribs expand and vice versa, your patient may have a flail segment, which is a section of ribs that have broken completely away from the rib cage. This is a serious sign and should be fixed when found. You want to tape down a folded shirt, saline bag, or bulky dressing over the wound site. Tape it down tightly, because you’re trying to prevent the flail segment for engaging in the paradoxical movement that can compromise breathing. Be highly suspect of a pneumothorax / hemothorax if you see this. This video shows it pretty well. Look how much effort this guy is putting into breathing. If he doesn’t get help soon, he’s going to tire out and crap out.

If you find puncture wounds over the chest, then cover them with occlusive dressings like Vaseline gauze, plastic wrap, or some of the fancy chest seals like the Asherman, Halo, and Bolin. If you are using Vaseline gauze or plastic wrap, tape it down on three sides only and leave one side open to allow for burping the wound.

Vaseline gauze. Cheap and effective.

If the wound is gurgling, then you very likely have a pneumo / hemothorax to deal with. Make sure to count all of the puncture wounds and their locations. If you can, roll the patient on his side and assess the back for wounds and injuries. If there are more holes in the chest / thorax area, count them, note their locations, and get occlusive dressings on them. Don’t worry about exit or entry classifications. What matters is the number of holes in your patient’s body and what the implications are for what’s happening inside where you can’t see.

A quick talk about hemothorax and fluid in the lungs. A hemothorax is blood filling up the space in the chest that once was filled by your now collapsing lung. The space in your chest is big enough to hold 25-40% of your blood supply. Remember the shock table from Part I. 25% of blood volume and above is Stage III and Stage IV hemorrhages. Like a pneumothorax, the blood in the chest cavity prevents the lung from fully inflating, but is less likely to result in the same amount of tension as a tension pneumothorax. Needle decompression will not be an effective treatment for a hemothorax. A chest tube placed on the midaxillary line (think inline with your armpit) in the fifth intercostal space in the ribcage is going to be a better solution in getting the blood out. This is not something that you see done in a prehospital setting. If you know you have a hemothorax in the field and your patient is dying from it, you may need to place your decompression needle in the fifth intercostal while the patient is supine and try to get some of the blood out. If you are having to do this, your day is very, very bad.

Fluid in the lungs is just that. It can be water, blood, vomit, beer, you name it. The fluid fills the alveoli and prevents O2 and CO2 from exchanging at the capillary membrane. Get enough fluid in your lungs and you will not be able to exchange enough gas to stay alive and will die quickly. The alveoli lose their surfactant and collapse, making it impossible for them to continue to hold and exchange air. This condition is called atelectasis and it is very bad. People who survive drownings can have this happen to them days after they are rescued.

DISTURBING CONTENT WARNING. A MAN DIES IN THIS VIDEO
The video below shows a scumbag who got shot for trying to steal. It looks like the guy who blasted him got a good lung shot and hit some blood vessels. Notice the frothy, bright consistency of the blood and how quickly the guy deteriorates once he starts coughing it up. Most likely he aspirated his blood into both of his lungs and ultimately drowned in his own fluids. Not pretty. Fixing this guy would require lots of suction, positive pressure ventilations, endo tracheal intubation, lots of diesel fuel or helicopter fuel to get him to the trauma OR ASAP to get the vessels spewing into his lungs closed. Lesson? Armed robber is a poor career choice.

Abdomen

Inspect and palpate the abdomen. If your patient reports pain anywhere in the abdomen, palpate that area LAST. You are feeling for rigidity and abdominal guarding, where the patient flexes the abdominal muscles when your palpating causes pain over an inflamed or injured organ. Also look for rebound tenderness, which is pain AFTER you take your hands off the abdomen and the abdominal wall returns to its normal position. This could be a sign of something – like blood – irritating the peritoneum, which is the lining of the abdominal cavity. Look for signs of ecchymosis on the skin of the abdomen. It can indicate severe blunt force trauma to the abdomen.

Flank ecchymosis from blunt force trauma to the abdomen.
Source: http://www.wikidoc.org/index.php/File:Blunt_abdominal_trauma.jpg

If you see something pulsating in the patient’s abdomen, DON’T FUCKING TOUCH IT. It could very well be an abdominal aortic aneurysm, which means their descending aorta may burst open at any minute. Find out what this patient wants to say as last words to anyone he cares about, because this finding in the field is very grim. Very carefully load him into a stretcher and take a nice gingerly trip to a vascular surgeon to try and fix it.

Trauma to the patient’s upper right abdomen should make you highly suspicious for a liver laceration or injury. The liver is very vascular and can bleed profusely. Keep a keen eye out for shock in these patients. The same thing holds true for the upper left side of the abdomen with the spleen. Watch for distension in the abdomen and signs of shock, indicating an internal bleed.

If the patient has an evisceration, which is where the intestines herniate through the abdominal wall and the skin, soak a dressing in sterile water or saline and place it over the intestine. Cover that with plastic and tape it down. You want to keep the tissue moist. DON’T shove the intestine back in the hole. It’s already been exposed to germs and dirt on the outside and you can make any rupture of the small bowel worse by spilling gastric contents into the abdomen, thus making a bad situation worse. This is not necessarily a life threatening condition, and you may be able to skip over it to continue your assessment. Let the patient’s condition guide you on this.

Evisceration from a knife wound to the abdomen. Source: http://www.trauma.org/index.php/main/images/C13/

Evisceration from a knife wound to the abdomen.
Source: http://www.trauma.org/index.php/main/images/C13/

If your patient has been shot in the abdomen, any and all of the above injuries can occur simultaneously. Count the holes, note their positions, and place absorbent dressings over everything to help with bleeding. If you can roll the patient on his side to look for wounds on his back and treat them, do it. DON’T pour hemostatic agents into the wounds. If an evisceration is present, follow the above treatment. Allow your patient to bend his knees when laying supine when he has an abdominal injury. This alleviates some of the pull on the abdominal muscles and wall and alleviates some pain.

The abdomen is a magical, mysterious place where a lot of stuff can go wrong. You have to suspect a lot of different injuries in any kind of trauma because you have different kinds of organs and organ systems all in one compact area. Repeated patient assessments are key with abdominal wounds.

Pelvis

Assess the pelvis by LIGHTLY pressing down on the hip bones (illiac crests) as well as inward. Did I say lightly? If your patient screams at you and tries to choke you out, then there’s probably something wrong. If you feel crepitus with either press, something is VERY wrong and your patient has a fractured pelvis. This is a critical injury because a pelvic fracture can bleed 2000ml of blood in short order. That’s an instant Stage IV hemorrhage with decompensated to irreversible shock as a perverse reward. You’ll need to create a pelvic binder to help stabilize it, reduce bleeding, and reduce the volume of the pelvic cavity for blood to pool. Wrap a sheet, KED, a cut up foam sleeping mat with belt, whatever, under your patient and around his pelvis and secure it so the pelvis cannot be moved around. Very carefully get your patient onto a long board or stretcher and pack voids to minimize movement. Be on high alert for shock and treat aggressively. If there are bullet holes in your patient’s pelvis, the treatment is the same with the additions of counting the wounds, noting their locations, and applying dressings. The video below shows good technique in creating a pelvic binder.

Legs

Inspect and palpate your patient’s legs. In the upper legs, we are very concerned about the femoral artery and the femur. Femur fractures can lose 1500ml of blood pretty quickly, so be prepared to aggressively treat for shock if you see deformity and massive bruising. If a femur fracture is found or suspected, treat it when found, as it is a life threat because of the amount of blood that can be lost.

Pic below shows some good bruising:

Source: http://lowerextremityinjury.pbworks.com/w/page/3995265/Femur%20Fracture

A closed femur fracture, which means the bone has not penetrated through the skin and is visible, can be treated in the field with a traction splint. These are not things you carry in your daily kit, so the best thing you can do in the field is to supply manual traction. A patient with a broken femur is likely to present with the injured leg shorter than the uninjured leg. The x-ray below illustrates how the now two-piece femur is out of alignment.

Have one of your team members apply traction by grabbing the foot of the injured leg and pulling downward (caudally) to get the bones realigned. This also helps reduce the pain. Have the rest of the team poke around and find materials to make a hasty traction splint, because it’s going to be hard to have someone holding traction on a casualty you need to drag out of the woods. Below is a great example of the hasty traction splint. Be creative, have fun with it.

hasty-traction-splint

Source: http://wildernessarena.com/skills/first-aid-health-and-first-aid/treating-broken-bones

 

Key to any extremity injury is to check for pulses in the extremity south of, or distal, the injury site. On this femur fracture, you can check for a popliteal pulse on the back of the knee, or for a posterior tibial pulse just behind the interior ankle bone (aka the medial malleolus). Do this before applying traction, after applying traction, and after applying the splint. Continue to check for those pulses routinely, especially when you are moving your patient across country. Here’s where to find the posterior tibial pulse and the dorsalis pedal pulse as a bonus.

You want to try and keep the tissue distal the injury perfused as much as you can to avoid compartment syndrome from developing. The leg is a big hunk of meat, and if all of the tissue south of the injury gets starved of oxygen and dies, you are going to have a mess of acids, toxins, and the wrong kinds of electrolytes flood back into the bloodstream when circulation is restored. This can cause cardiac arrest. No shit.

If you have an open femur fracture, where the bone is sticking out through the skin, life just got more complicated.

Now THAT is sexy. Doesn’t that look like fun?
Source: http://www.jacknaimsnotes.com/2013/07/image-of-day-19-open-fracture-of-right.html

In the field, it is highly unwise to put traction on this injury, because you risk causing more damage to the vasculature and nerves in the leg by letting the sharp bones slice their way back through the meat in the leg. Furthermore, you increase the risk of infection. So the thing to do here is to tell your patient “Sucks to be you, brah,” then stop any active, life-threatening bleeding (if you did your blood sweep at the start, you’d have found this already, but we’ll do this anyhow), and now you FINALLY get to use that Tier I, Joint Task Force, Operational, Operating CAT-T, you motherfucking OPERATOR! First – but fast – check for popliteal and pedal pulses distal the injury to see if there is any circulation. This helps you gauge how bad the injury is. If no pulses distal the injury, then we know the tissue has not been getting perfused for a while. Apply your CAT-T until the bleeding stops and you can confirm lack of pulse distal of the injury if it was there before. Here’s a video on application of the CAT-T. Strap your Oakleys and Multicam on and enjoy.

Make sure you mark the time you applied the CAT-T. You can do it on the tourniquet, the extremity, or the patient’s forehead. Example: “T 1345″ means tourniquet applied at 1345 hours.

Next cover the bone ends with dressing soaked in sterile water, then dress the wound and bandage it up. Get the patient loaded up and pack towels, clothing, whatever you can around the leg to immobilize it. A splint may be in order, but again, NO TRACTION. Just try to keep the thing immobilized.

Any amputation occurring at the upper leg will be treated the same way as the open femur fracture. Stop life threatening bleeding with a tourniquet or tourniquets and treat the patient for shock.

If your patient is laying on the ground with one leg shorter than the other with his toes pointing inward (medially) while screaming in pain so loud that you have just alerted the forces of darkness in a 50 mile radius to your location, you may have a dislocated hip on your hands. Quickly expose the leg and look for any injury. If none is found, then you are narrowing it down fast. Check pedal pulses. Check the pelvis for crepitus and palpate the hip area for crepitus as well. If none is felt, you may be OK for treating for a dislocated hip.

Dislocated hip.
Source: http://emedicalppt.blogspot.com/2011/07/hip-dislocations.html

While painful, if pedal pulses are present and there is no sign of any injury, this is not a life threatening injury. However, the amount of screaming you will hear from your patient will make you want to fix it to shut him up. Grab an extra cartridge from your kit and give it to your buddy to bite on. He’s going to need it. Here’s the Captain Morgan hip reduction technique.

Now, we’re not supposed to do this as pre-hospital providers, and I sure as hell don’t do this in the course of my job. However, if all that’s left of my hometown is a mushroom cloud and the screaming of my tribe brother is calling the drones of the Geheime StaatsPolizei to come over and Hellfire us out of existence, I’m not worried about getting my patch pulled anymore. In other words, only do this in extreme emergencies where there is no other help available. Otherwise, get the patient to the ER / CCP/ base and let the doc or the PA do the reduction.

Once you do the reduction recheck the pelvis, hip area, and pulses. Assess for any swelling or bruising. Make sure you didn’t break anything by fixing it.

If your patient is lying on his back with one leg potentially shorter than the other and the toes on the injured leg point outward (laterally), suspect a hip fracture. This one is very serious because a hip fracture means a femur fracture, a pelvic fracture, or even both.

Hip fracture. Note the shorter leg and lateral rotation.
Source: http://www.utahmountainbiking.com/firstaid/fxhip.htm

You want to immobilize the injured leg and avoid doing anything to it that would open up the fracture even more. Check for distal pulses. Treat with a pelvic binder, packing the voids around the leg, and shock measures.

Further down the leg, you have the tibia (shin bone) and fibula. If these are fractured, you don’t put them in a traction splint like the femur. In the context of a rapid trauma assessment, these may be ugly, but not life threatening. The key is how much the break is bleeding. If it looks like an artery has been damaged because blood is spurting out of it or the calf has swollen into a purple basketball in a closed fracture, you’ll need to fix it right away. If there is minimal bleeding and the patient has other things going on, note the wound and come back to it after you have taken further stabilization measures.

An open tibia / fibula fracture. Source:http://commons.wikimedia.org/wiki/File:Tibia_%28Shinbone%29_Shaft_Fracture.JPG

An open tibia / fibula fracture.
Source:http://commons.wikimedia.org/wiki/File:Tibia_%28Shinbone%29_Shaft_Fracture.JPG

In the case of a life-threatening bleed, apply a tourniquet above the knee and tighten it until the bleeding stops and there are no distal pulses. Mark the time, treat for shock, and Charlie Mike.

In a closed tib/fib fracture with obvious deformity, check the distal pulses (noticing a theme here?). If there are none you can try a reduction in the field to get them back – ONCE. Hold the patient’s foot and apply traction by pulling it caudally until it is inline with the upper part of the tib/fib. Check for distal pulses. If you got it right, they’re back. If you missed it, you’re done anyway. Splint the lower leg. Check for pulses after splinting.

Here’s a great example of an improvised splint for the lower leg. Lots of camping gear up on this one. Always be thinking about how you can repurpose your gear for medical use.

Source: http://www.idratherbehiking.com/

An open tib/fib fracture should be treated the same way the open femur fracture was. DON’T perform a reduction. Leave it as is. Check for distal pulses. Stop life threatening bleeds with a tourniquet placed above the knee. Recheck pulses to ensure there are none. Cover the open bone ends with dressings soaked with sterile water or saline. Dress the wound and splint it.

For gunshot wounds and puncture wounds in the legs, if you can control major hemorrhaging with direct pressure, packing the wound with hemostatic gauze and/or hemostatic agents, that is preferable to a tourniquet because you are not cutting off circulation to the entire extremity as you do with a tourniquet. If a tourniquet is your only option or there is just too much bleeding going on, apply the tourniquet above (proximal) the wound site. As before, check distal pulses before and after applying the tourniquet and mark the time it was placed. Dress the wounds with gauze and hemostatic agents. Assess the extremity for motor and sensory by having the patient wiggle his toes. Run a marker or handle of your EMT shears along the bottom of the foot to test for sensory. Note if there are any deficits, as the bullet may have caused some nerve damage.

Arms

Checking the arms is very much the same as the legs. You are looking for life threats and need to stop those as they are found. That’s pretty much damage to the axillary, brachial, radial, and ulnar arteries causing a life-threatening bleed. Check for pulses distal to any injuries as well as sensory and motor function. Attempt to control bleeding with direct pressure, wound packing, and hemostatic agents. If that fails, place a tourniquet proximal the injury and tighten until bleed stops and there are no more distal pulses. Mark the time you placed the tourniquet, dress and bandage the wounds.

Open fractures need to be left as-is. Check distal pulses and motor function of the hands. Stop any life-threatening bleed with a tourniquet proximal the wound. Cover the open bone ends with dressings soaked in sterile water and saline, dress the wound, splint it.

After splinting the wound, apply a sling and a swathe to immobilize the arm. If you are dealing with a clavicle fracture from earlier, now might be the time to deal with it. Best treatment for it is a sling and swathe. No splint needed for the clavicle alone.

Source: http://nursing411.org/Courses/MD0533_Treat_Fract_Field/5-06_Treat_Fract_Field.html

If the fracture is located in the upper arm, the treatments are the same for open and closed fractures with the major difference in the splinting. You may need to create a long-board splint and then swathe it to your patient’s body. Below is a nice illustration of a long-arm splint.

Source: http://www.medtrng.com/cls2000a/lesson_12_perform_first_aid_for_.htm

Back

Once you have assessed the patient and stopped all life threats while he is supine, maintaining cervical spine (c-spine) stabilization (if indicated), you will log roll the patient onto his side and assess his back. The person at the head of the patient maintaining c-spine directs the call on when to roll the patient. While the patient is on his side, expose his back and look for any deformities or injuries. Treat life threats and note the locations of the injuries. Below is an OK video of a log roll and immobilization of a patient to a long board. The assessment of the back is pretty shitty. DON’T be that nonchalant about it. EXPOSE the back and put your hands on the patient to feel for crepitus or vertebrae that are out of alignment.

The SAMPLE history

If your patient is awake, or there are people around who know what happened and/or have knowledge of the patient, use this simple mnemonic to get information.

  • S: Signs and symptoms of injury / illness
  • A: Allergies to drugs, foods, insects, anything
  • M: Medications the patient is currently taking for any chronic malady or short-term condition
  • P: Past medical history including chronic conditions like diabetes, hypertension, heart problems, as well as major surgeries like coronary bypass surgery, mastectomies, abdominal surgeries, etc.
  • L: Last oral intake, medications, food, drugs – legal and recreational, liquids – virgin and alcoholic, etc.
  • E: Events leading up to the event. What was going on before whatever happened, happened?

After this, get a set of baseline vital signs including; AVPU, blood pressure, pulse, respirations, and if you have the equipment to do it, blood glucose level, pulse oximetry (SPO2), and end-tidal CO2 (ETCO2). Recheck vitals and reassess from head-to-toe every five to fifteen minutes depending on the severity of the patients condition.

Even though you’ve stripped the patient down to find wounds, make sure you cover them back up ASAP to keep them warm and continue to watch out for shock.

In closing

That pretty much sums up the rapid trauma assessment and the also-rapid follow on assessment. While it is a lot of information, practicing assessments can help you get this entire process down in under ten minutes. The goal on any trauma scene is to get the patient stabilized and in transit in under 10 minutes, with the ultimate goal of getting him on the operating table in under 60 minutes from the time of injury.

In Part III, we’ll go over some philosophy on treatment, training, and what a medical system may look like in SHTF/WROL.

In Part IV, we’ll look at some types of injuries that are most likely to occur in a bullets-flying SHTF/WROL scenario.

In Part V, we’ll get all gear queer and talk medical equipment.

Let’s talk trauma, part I: Physiology and the pathophysiology of shock

scream-come

Today we’ll discuss trauma in a SHTF/WROL, the world is tits-up, we’re getting shot at by shitheads, and it’s just me and my buddies out in the middle of nowhere trying to keep it together and keep people from croaking from their injuries.

In this tome, we’ll cover some basic medical concepts around normal physiology, the pathophysiology of shock, what creates the life threats that we need to treat in the field, and gear options for the prepper.

I’m a street paramedic that loves his job and wants to spread as much knowledge as far as I can to anyone that is interested. I am not a doctor, so everything I write in here should be taken as the ramblings of a medical geek, but not as formal instruction. Consider all of this a giant “FYI” and anything that feels like instruction should be mentally prefaced with “if it were me treating me, then I would…”

We’ll focus on injuries like gunshot wounds, fractures, burns, and overpressure injuries from explosions and the like. I mean, the end of the world is upon us and all.

Basic physiology

Let’s look at how you are supposed to work on any given day; when the sun is shining, your wife loves you, and the dog obeys your commands. I am going to try and keep this BASIC, BASIC, BASIC, so any med guys feel free to chime in with comments / additions. I’ll probably leave some stuff out in the interest of brevity and because we’re talking field, SHTF medicine here and not ER / OR / radiology lab medicine.

When things are in good order, you are considered to be in homeostasis, which has all of your major organ systems, nervous system, circulatory system, your metabolism, your electrolytes, etc., all in good working order.

Everything in your body is being perfused properly. Perfusion is the supplying of oxygen and nutrients to the body tissues as a result of the constant passage of blood through the capillaries[i].

Source: https://en.wikipedia.org/wiki/File:Capillary_system_CERT.jpg

The capillaries are the smallest blood vessels in your body and are the ones responsible for getting fresh, oxygenated blood to the organ system cells and also removing any cellular waste products and CO2 from the same cells.

Perfusion enables cellular respiration, which in a very basic form, is the burning of glucose (sugar) and exchange of O2 to create energy, with CO2 and waste products being removed from the cell. All of your cells in your body do this to varying degrees. It is known as aerobic metabolism and it means that oxygen is helping to produce large amounts of energy at the cellular level. Anaerobic metabolism has the cell creating energy without oxygen. It creates much less energy than aerobic metabolism, and more importantly, it creates more waste products than aerobic metabolism.

An animation of a typical human red blood cell cycle in the circulatory system. This animation occurs at real time (20 seconds of cycle) and shows the red blood cell deform as it enters capillaries, as well as changing color as it alternates in states of oxygenation along the circulatory system. Source: https://upload.wikimedia.org/wikipedia/commons/7/75/Erytrocyte_deoxy_to_oxy_v0.7.gif

The capillaries pick up the CO2 and waste products, and they flow into the venous system, where ultimately the lungs, liver, and kidneys filter out the bad stuff and blow off CO2.

The lower airway and lungs in gross form, are broken down from largest to smallest airways as follows:

Trachea, right and left mainstem bronchi, lobar bronchi, segmental bronchi, bronchioles, and alveoli.

The airway. Source:  https://en.wikipedia.org/wiki/File:Illu_conducting_passages.svg

bronchial anatomy details normal

Bronchiole leading into the alveoli. This is where the gas exchange occurs.
Source: https://en.wikipedia.org/wiki/File:Bronchial_anatomy.jpg

The alveoli are tiny airbags that are the termination point of the lower airway. They are covered in a liquid called surfactant, which helps keep them keep their shape. If surfactant is missing, the alveoli can collapse and bad things will start to happen.

Respiration is the exchange of gases in the lungs at the alveoli and capillary beds. The O2 passes through the alveoli into the capillary and thus into the circulatory system, and the CO2 passes from the capillary over into the alveoli where it is expelled through ventilation. Ventilation is the mechanical operation of the lungs and the movement of air into and out of the lungs. Ventilation and respiration are related, but they are NOT the same thing. You can have ventilation without respiration, which we will cover later.

In order to remain in homeostasis, the body must have adequate ventilation, perfusion, and respiration. The most critical organ systems to keep alive are as follows:

  • Brain and central nervous system
  • Heart
  • Lungs
  • Kidneys
  • Liver

If one of these systems craps out on you because a breakdown in perfusion, you are having a very bad day.

Shock and the pathophysiology of shock

Shock is also called hypoperfusion, with “hypo” meaning “under” in Greek. If you are in shock, you are not being adequately perfused. There is not enough oxygenated blood circulating throughout your body to keep everything perfused and keep an aerobic metabolism going.

We’re just going to look at hypovolemic shock, which in a SHTF, bullets-flying, life sucks scenario, is the most likely shock you’ll be dealing with because of the kinds of injuries that happen in said scenario.

Imagine that all of your blood vessels are one giant container full of fluid, your heart is a hydraulic pump to keep the fluid moving, your lungs are your intake and exhaust manifolds, your kidneys, liver, and spleen are various oil filters, and your brain and nerves are your battery and electrical system.

Your container, if you will. Note the positions of the radial, brachial, femoral, and carotid arteries. These are your primary pulse points in a rapid trauma assessment.
Source: https://en.wikipedia.org/wiki/File:Circulatory_System_en.svg

Hypovolemia is a low level of blood in your container from it springing a leak, hence the term “hypovolemic.” There are three stages in shock that you need to pay special attention to:

shock-table

Compensated shock: After someone is injured, you need to be very watchful for the signs and symptoms of compensated shock. In this stage, the body is compensating for the loss of blood occurring somewhere within the circulatory system. The body will constrict peripheral blood vessels to shunt blood to the torso and head in order to keep the main organ systems perfused. The patient’s heart rate will go up. Blood pressure will remain normal, and sometimes even increase slightly. Respirations will increase and sometimes increase in volume. He will become pale and cool and look freaked out. Some people want to fight, some people want to talk, some people start fidgeting around. In any case, you need to get it on here to prevent your patient from slip-sliding further down.

Treatment at this point is to stop bleeding wherever and however you can. If you have IV fluids, get a line (two is better, and try to have them with at least 18gauge catheters) started and start getting saline or Lactated Ringer’s infused. If you have a BP cuff, you want to keep the systolic BP < or = to 90mmHg. The reason for this is that you want the body’s clotting mechanisms to go to work over whatever wounds there are. If a clot is forming over the broken vessel, a higher BP can blow the clot off and your patient will start bleeding to death again.

If you have oxygen on hand, get it flowing. If you have a non-rebreather mask (NRB), 15 liters per minute (LPM) is recommended. A nasal cannula can be set 2-4 LPM. If you have to assist the patient with ventilations with a bag-valve mask (BVM), 15 LPM is the right setting as well.

Get the patient wrapped up in blankets and keep them warm. This is huge. People forget this a lot, and it is one of the most important things you can do.

Decompensated shock: This is an ominous change and does not portend for a very good outcome unless you are very aggressive in your resuscitation efforts. The patient’s BP will drop precipitously and his pulses will become very weak, even at the carotid and femoral arteries. If the pulses are fast, his heart is still trying to compensate by pumping blood faster, but there just isn’t enough blood. If the pulse is slow, his heart is shutting down because there isn’t enough blood to keep the heart muscle perfused. The patient’s mental status will deteriorate rapidly to unconsciousness. Breathing will become slower. Organ systems will start to fail. Blood becomes very acidotic and waste products from anaerobic metabolism begin to build up. This is a highly toxic state to the body. Decompensated shock does not last for very long and very quickly becomes irreversible shock.

Treatment for this is the same as compensated shock. If you have blood products around, they are going to work better than isotonic crystalloids like saline, but it may be too late already and you’d be better off using them on someone else.

Irreversible shock: This is fatal and there is nothing you can do for this patient except give them last rites. Cells die from lack of oxygen and break apart. The capillary layers open up and the patient starts bleeding from everywhere in a state known as washout, where lactic acid, CO2 in the form of carbonic acid, coagulated red blood cells flood back into the circulatory system. The electrolyte balance in the body is upside down. Organ systems are now dead or dying. This person is dying.

The above famous picture of one of the victims of the Boston Bombing is a great example of what a person looks like in compensated shock. He has lost a lot of blood. He is very pale. And very importantly, look at the expression on his face. He looks kind of spaced out and detached. He’s not screaming in pain even though his legs have just been blown off. He’s just kind of hanging in there. This guy is definitely on the line between compensated and decompensated shock. Remember that look. If you ever see something similar to it, you have a very short time to work.

The Triangle of Death

In shock, there is a thing known as the Triangle of Death. These are the three things that are absolutely, 100% sure to kill someone dead if they manifest.

Source: https://en.wikipedia.org/wiki/File:Trauma_triad_of_death.svg

  • Coagulopathy: where the blood clotting / coagulation cascade stops
  • Hypothermia: the patient’s core temperature drops
  • Metabolic acidosis: lactic and carbonic acid flood the system

Now here’s the rub about resuscitation for shock.

A human’s pH level is normally around 7.35-7.45 on the pH scale of 0-14, with 0 being totally acidic and 14 being totally alkaline. Pure water at scientific room temperature of 25°C (approximately 77°F) has a perfectly neutral 7 on the pH scale.

The two isotonic crystalloids we use in the field for fluid resuscitation are 0.9% Normal Saline, which has a pH of 5.5, and Lactated Ringer’s (LR) solution, which has a pH of 6.5.

Secondly, both crystalloids are infused at room temperature, but our bodies run at 98.6°F.

So think about that for a minute. We are putting a cold, acidic solution into a patient that will die if he gets cold and acidotic.

To be fair, LR actually acts as a buffer and ultimately promotes alkalinity because it is transformed into bicarbonate AFTER it goes through the liver. However, it’s initially acidic when it goes into the venous system.

Hypothermia metrics in normal adults are as follows:

  • Mild hypothermia: 90-95°F core body temperature
  • Moderate hypothermia: 82-90°F core body temperature
  • Severe hypothermia: <82°F core body temperature

This is something to think about when you are treating for shock. Consider warming fluids before administration and possibly using sodium bicarbonate if available.

The fact is, there’s nothing better to treat blood loss better than more blood, but you do what you can in the field.

In Part II, we’ll look at triage and treatment choices, and go through the awesome Rapid Trauma Assesment.



[i] Bledsoe, Porter, Cherry, Paramedic Care Principles & Practice (Pearson Education, Inc. 2009) vol 1, p213.

Too cool not to copy: The Mountain Guerrilla and “The Team Sergeant” on load bearing gear

Read. Learn. Enjoy.

An excerpt:

I wore (and still occasionally wear) the old mohawk aviators vest under the LBE in case the ruck has been dumped/lost-particularly in the winter (shorter vest with bigger pockets that fit nicely between ALICE LBE or similar side openings). The vest is packed with redundant nav gear (compass/maps), meds, key clothing (wool hat, socks, gloves), all my survival tools/gear (multiple fire, a poncho, 550, multi-tool, some wire, etc), spare eyeglasses, a couple of different signaling means (mirror, light, cut-down VS-17), seven days of chow (broken down MRE mains, bullion cubes, hard candies), water storage with purification and yes…a second sidearm with four extra mags. In the old days I carried a survival radio on it, too. I can wear that vest under my fatigue shirt or parka and I never had problems with it getting in the way or snagging on shit. It NEVER came off except to change a t-shirt once every week or so. I can sleep comfortably on my side with it (I don’t snore in that position) unlike with any LBE with 15 mags and other assorted gear.

The SV-2 / OV-1D vest:

The OV-1D

HT: WRSA.

Please remember to do your PT. :)

Retired Boston PD stooge scolds serfs for not embracing door kicking

EndofRepublic

Just an “inconvenience.”

Retired Boston PD guy writes letter to the editor about their conduct during the Boston Bombing that perfectly illustrates the disconnect between many enforcers and the people they are supposed to be serving.

The people in this story complained about having to stay in their homes and being intimidated by “big scary men in black with guns” (I’m sure our female officers who were involved would take exception to that characterization). Apparently since no one, let alone the residents of Laurel Street, knew where or even if Dzhokhar Tsarnaev was still in the area, I suppose a cursory search of the area while explaining police tactics to each and every neighbor would suffice in their minds.

Lastly, as to the issue of PTSD, speak to the officers who were at the finish line who ran toward the explosion to help the victims while not knowing if there was a secondary device. Speak to the officers who had to guard a gigantic crime scene for days on end. Sit down with those officers who responded in Cambridge and had to view the body of MIT Officer Sean Collier, who was murdered . . . without a chance to defend himself. Have a cup of coffee with the officers that were dodging bullets fired at them and bombs thrown at them. Listen to a combat veteran who’s been deployed multiple times about the trauma that they still carry with them to this day.

That is PTSD, you were inconvenienced: Recognize the difference, let the professionals do their jobs, and keep your second guessing to yourselves.

Wow. Where does one start.

You guys ignored the supreme law of the land. In other words, you broke the law. People have a pre-existing, natural right to be secure in their homes from unwarranted searches. It is plain as day and there is no wiggle room on this one. Your conduct that day towards your fellow citizens was dishonorable and disgraceful. The people you harassed are on the same side as you are, but you treated them like some kind of occupying army in a hostile country. If you want to play COIN, you have to be nice to people who can supply information and help with the search. That’s the thousands of eyes and ears full of intel that you could have used. Like the guy who found Tsarnaev hiding in his boat by noticing a cover out of place. Something that all of the door kicking, stacking, and generally unprofessional behavior didn’t produce. The Bill of Rights does not disappear because it inconveniences you in doing your job. It is the law, and you are expected to follow it.

Driving down residential streets in up-armored humvees with locked and loaded M4s muzzle-sweeping people looking out their windows is not the act of a friendly group of individuals.
I believe you guys on Team Blue fired over 300 rounds that day when someone pointed guns your way. You might want to remember how someone pointing a gun at you made you feel.

And please, stop with the “poor me” schtick. You’re like a feminist. Big, tough, mean and not to be trifled with, yet a victim as soon as someone starts to question you. Nobody stuck a gun in your mouth one day and said “go be a cop.” Nobody sticks a gun in your mouth every morning and forces you to go to work. That is the profession you chose with all of the carnage and degeneracy that comes with it. I get that its dangerous sometimes, but don’t whine about it. It was your choice.

And stop with the comparison with combat vets. We are not at war with our own people here. You were not on patrol in Ramadi or the Korengal Valley. You did not have small units of guerrillas and grenadiers ambushing you. You were not getting sniped at from multiple directions while trying to move. You were in Boston. It was a bad day to be sure. Four good people died. All of them had plenty of life left to live and plenty to offer the world. Let’s not forget there are dozens of families that have huge physical and mental wounds from the bombs. They count too. Just stop with the “us vs them” thing implying people in uniforms had it worse that day than anyone else. It diminishes you personally and diminishes the entire profession. A lot of people, badge or no, are dealing with the same thing from the bombing. So just stop it.

The people you rousted that day were not “inconvenienced.” They were violated, pure and simple. No amount of your passive-aggressive self-pity can hide that fact. Get over yourself.