Musings of a Law Enforcement Paramedic – Part 2, by LEO Medic

Yesterday, we read about certifications and training to prepare to “doctor” your family/group in a post-SHTF scenario. Today, we have part two of this five-part article, looking at first aid in some serious, even under fire situations.

TCCC Lessons:

In addition to teaching basic EMT, I am a Tactical Combat Casualty Care (TCCC or TC3) instructor, as well as an instructor for the associated Trauma First Responder and Law Enforcement First Responder classes. As anyone in EMS or nursing can attest, one of the first tenants of patient care is that the scene must be safe before care is provided. If the scene is not safe, you do not enter and do not provide care. TCCC is a great class for EMS providers, nurses, and doctors because it looks at what happens and what to do when the bullets are still flying and the scene is not safe. It is a two or three day course, with scenario-based training and skill stations.

I know that TC3 has been covered in a previous blog post by Cowpuncher.

That was an excellent article, and it provides a great overview of TC3. Read it and brush up.

I will try not to rehash the work of another, and will limit myself to worthwhile observations and experiences with teaching, training, and practicing TCCC, as well as new updates to the protocols. This is material that you need to be intimately familiar with. It will save lives. Hopefully this will encourage you to spend some time with your IFAK and medic gear. Guns are sexy. Wound packing is not. Don’t neglect it.

For those not familiar with TC3, the military looks at all combat deaths and does autopsies, determining cause of death and inputting vital information into a database. Of all deaths, they then look at preventable deaths. What they found from analyzing all of this data was that approximately 25% of soldiers were dying of potentially preventable deaths (The other 75% were killed outright, or suffered trauma incompatible with life.) The 25% of preventable deaths was broken down as such: 9 % died from external hemorrhage. 5% died from tension pneumothoraxes. 1% died from airway complications. Another 10% died from infections and complications of shock. Starting in the Special Ops communities in the 1990’s, TCCC was born as a solution to this. Its success has been remarkable. The Rangers have made it a goal to have all members TCCC certified. While the overall military preventable death rate is 24-25%, the Ranger preventable death rate is 3%. (So out of 100 deaths, only three could have been prevented with better field care. This is a remarkable rate.) In a nutshell, the course is external hemorrhage control and treatment for other preventable causes of death, set in the context of small squad tactics with the back drop of still accomplishing a mission. The application at TEOTWAWKI is huge. These truly are lessons learned and written in blood. I hope that by passing those lessons on, those deaths may continue to find a purpose. Why I like TC3 versus standard first aid is that it blends medicine and tactics, and often combines the two. It also understands that everything has a time and place. The focus is on skill mastery, knowledge of the application (both how and why), and thinking on your feet. The three objectives of TCCC are: Treat the casualty, prevent additional casualties, and complete the mission.

There were two recent police shootings in Utah and in Missouri where the officer shot a suspect, then used his IFAK to save the suspect’s life. Contrast this professionalism to the chokehold death by NYPD, and lack of care after. This training works.

The backbone of TCCC training is the Individual First Aid Kit (IFAK). This kit has also been gone through in detail in other posts on the blog, but for those unfamiliar, it’s basically a tourniquet, QuikClot gauze, regular gauze, an Israeli dressing, and an NPA (Naso-pharyngeal airway). It is also called a blow-out kit or gunshot kit. Some versions include an antibiotic pill pack. Within the past year, as a result from analyzing combat deaths, the military switched to the IFAK 2. This version includes new additions– a second tourniquet, an occlusive dressing, shears, an eye shield, and second QuikClot Gauze. I will go over the contents in more detail below.

TC3 breaks up care into a few phases. The first is care under fire. What care do you give while still under fire, if you or a squad mate is wounded? The initial response is to shoot back and get to cover. Prevention of further casualties is vital. Once at cover, the only care that is given while bullets are still flying is tourniquet application for a massively hemorrhaging wound. If it is not spurting blood, it can wait. You can bleed out in under three minutes from a good arterial bleed, and in the field, blood is like toothpaste– it’s hard to put it back in the tube, so keep it in. QuikClot gauze requires three minutes of pressure to work, so this is not amendable to a fire fight. If in doubt, tourniquet it up and shoot back. Ideally, you would move out of the kill zone /off of the X first and be able to self-apply. If your squad mate is shot, direct them to cover, and direct them to apply the tourniquet. If your squad mate is shot and is unresponsive and not moving, they are most likely dead and not worth the risk of a rescue attempt. That’s brutal, yes, but it’s honest. There are too many stories of five or six troops getting killed trying to ”rescue” one that is already dead or beyond saving. I have had multiple students remark that the tourniquet scenario is like a mag exchange or tactical reload. Shoot back, get to cover, do it quickly, and keep fighting.

It is almost impossible to keep manual pressure on a good bleed while moving a patient. In addition to stopping bleeding, tourniquets allow easier movement of patients after treatment, or the completion of a specific task. An Air Force PaveHawk pilot on an evac mission was shot through both thighs by small arms fire. A PJ who was on board for the rescue mission crawled up into the cockpit, tourniqueted both legs, and the pilot was able to complete the mission. This is very similar to what happened to Blanca in Patriots on a close air support run. Rather than applying a scarf, if she had a few tourniquets handy to apply and was aware of TCCC, she may have fared better!

The Raid on Entebbe is a great example of the care under fire priorities put into practice. For those not familiar, in 1976 Israeli commandos undertook a daring raid to rescue 106 hostages taken during the hijacking of a flight that landed in Entebbe, Uganda. At the onset of the raid, Yonaton Netanyahu, the older brother of Benjamin Netanyahu, was shot in the chest and fell. As trained and instructed, the assault continued. Only 90 seconds later, 102 of 106 hostages were rescued, and all hijackers were killed. (More Ugandan troops were killed during the exit.) Netanyahu was treated after the assault and died from his wounds. The 90-second delay in treatment did not change the outcome for the injuries Netanyahu suffered, but a 90-second delay would have had disastrous effects for the raid. Good medicine can sometimes be bad tactics. You are still waiting until the scene is ”safe” to provide care, but now you are the one making the scene safe.

The next aspect of care is called Tactical Field Care. This is care when hostilities have stopped (or for wounds suffered from non-hostile means) and all efforts and energy can be focused on medical care of the wounded. Realize it is fluid, so you may go from care under fire to tactical field care, and then back into care under fire. TC3 now uses the acronym MARCH to help with priorities in field care. (For those of you paying attention, it mirrors the recent change from ABC’s to CAB’s in the EMS world, where major bleeds are initially addressed.) MARCH stands for:

Massive Hemorrhage- Stop any major bleeds not addressed in care under fire. Now is the time to think about using QuikClot, if it’s needed for a bleed you can’t tourniquet, or Israeli/pressure dressings on good venous bleeds.

Airway- Does the patient have one? Time for the head tilt chin lift or NPA insertion, et cetera.

Respiration- Cover any chest wounds with an occlusive dressing. Needle decompress any suspected tension pnuemos. Provide respirations if needed.

Circulation- Start an IV/Saline Lock. Prepare to treat for shock.

Hypothermia and Head Injury- Prevent hypothermia and hypoxia.

MASSIVE HEMORRHAGE

Tourniquets-

In putting together the IFAKs, the military did extensive testing. The only tourniquets that they approved are the North American Rescue CAT (combat application tourniquet) and the Soft-T tourniquet. Both consist of a strap and buckle with a windlass. They differ slightly, but both work well. I am partial to CATs. I think they pack easier and are easier to manipulate. The strapping is a little wider also. SWAT-T, another commercially available tourniquet, did not fully occlude blood flow in military tests, and was not recommended. The SWAT-T is a long strip of elastic rubber, like an exercise band. I have played with SWAT-T’s before. I carry some as a pressure dressing or second tourniquet. (I’ll share more on this later.) They are cheap, around $8, and small, so you see them in a lot of pocket IFAK kits. (By comparison, CAT’s tend to be pricey, retailing around $30, but you can find them new in package on eBay for around $15 each if you buy a few together.) In our own trials of the SWAT-T, it was very difficult to occlude enough blood flow to stop a pulse, even under ideal conditions. It is extremely difficult to put on one handed. They will work in a pinch, but with the availability of the CATs at $15, there is no reason not to go with these. You and your loved ones are worth the extra $7. On this same note, buy extra for training. Tourniquets will fail after repeated use. The strapping will stretch, and windlasses will break. We spray paint all of our training ones, so they will not get mixed up with duty ones.

The SWAT-T is not CoTCCC approved because it is not one-handed applicable, which was a requirement in the 2004 testing. With a two-handed application, you can wrench it down enough to stop blood flow. When I am talking about not occluding blood, I am talking about single-handed application to your own arm. A faint but palpable pulse was almost always there, especially if applied over a shirt during our testing of it. The military also found similar results with two-handed tourniquets being applied one handed, hence the requirement for one-handed applicability. In full disclosure, I carry both CATs and SWAT-T’s in my gear.

Try the different types, and see what you prefer. The SWAT-T is not my favorite but is very handy for the ability to tourniquet (relatively) and act as an occlusive or pressure dressing, in a small, cheap package.

Be mindful of items in pockets or of leg drop holsters when applying tourniquets. I have seen a photograph of a tourniquet that ended up around a backboard handle as well as the patient’s leg. They will work over clothing, but hard objects will interfere with the effectiveness.

On the CAT, the pressure bar (part under the windlass) goes on the artery side of the extremity. There are two slits that the strap can be fed through on a CAT. They come fed through the inner slit only. The one slit method is for one-handed application, such as on an arm. The second slit is for two-handed application, such as on a leg. The tourniquet must be pulled as tight as possible and should not take more than three turns of the windlass to occlude blood flow. Blood pressure still follows the laws of physics. The wider the area, the less pressure required. If one tourniquet does not stop the blood flow, apply a second just on the heart side of the first. This is not a bad use for a SWAT-T.

I have seen field use of makeshift tourniquets a dozen or so times. They have ranged from bungee cords to shoe laces to belts. None worked, and all but one was not needed, since direct pressure stopped the bleeding. Remember, tourniquets are for squirting arterial bleeds; otherwise, direct pressure is still the best option. On the one time it would have made a difference (actual arterial bleed-true femoral artery laceration after ATV accident), it was put on below the laceration (honest to goodness), and so it had no effect. I have used CATs twice– once on a mid-thigh amputation and on a boat prop cut foot. In both instances, bleeding was quickly controlled. It makes a difference having the right equipment!

Once a tourniquet is on, LEAVE IT ON until higher care is reached. Do not loosen periodically. BUT…in TEOTWAWKI, what if there is no higher care? So your spouse got shot, and you were able to apply a tourniquet and stop the bleeding. Now what? If you are the ”surgeon”, you may very well have to remove one. So in the event you do, have an IV established and QuikClot in place over the wound. Leave the tourniquet on the extremity, and loosen one turn while applying pressure to the wound with hemostatic gauze. If able to control the bleeding, continue with pressure and a pressure dressing over the gauze, while slowly releasing the tourniquet. If bleeding is still uncontrolled, simply retighten tourniquet. DO NOT LOOSEN UNTIL YOU ARE READY, AS THE HIGHER MEDICAL CARE TO ADDRESS THE ISSUE. You can also use the tourniquet to stop blood flow for surgery, just as Mary did in Patriots, while fixing the forearm laceration on Margie, using a blood pressure cuff. Realize also that if a large artery was damaged, a more invasive method of stopping bleeding needs to be applied before it can be removed.

Try applying tourniquets one handed, separately using your weak and dominant hand. Try it in the dark. Try turning out the lights and having a partner wet a part of their pants or sleeve. Find the ”blood” by feel, and then apply the tourniquet correctly. Be sure to feel for lack of a pulse when applying a tourniquet to ensure proper application. The first few times, find the pulse, and keep a finger on it while someone else tightens the tourniquet, so you can feel when blood flow is stopped.

Tourniquets are also very useful in and a great change up for training. When a tourniquet is on correctly, it hurts. We have used tourniquets as a ”distraction” injury during live fire drills. It is a lot harder to shoot and manipulate a pistol when your dominate arm is throbbing from a tourniquet. Another very useful training involves simmunition guns but can be used with paintballs as well. Airsoft will not work because you need ammunition that leaves a mark. Have the trainee actively shooting with a sims gun or paintball, and then have the instructor shoot them in either their arm or leg with the marking weapon. The trainee has to return fire, move to cover, and then correctly apply the tourniquet to whatever extremity was injured, above the wound.

Make sure you can reach your tourniquet with full battle rattle on and with either hand. Consider having two or three in various locations. (I carry one in my left pant leg cargo pocket and one front and center low on my vest.) Have one standard location for your squad, so you can find it by feel in the dark if need be on each other. My squad also purchased Spec Ops Brand (a SB sponsor!) medical pouches. These are standard MOLLE pouches with a red stripe on the flap to denote First Aid. Anytime you see that stripe, you know it’s the IFAK, so time is not wasted. IFAKs go on the outside of bags, not buried on the bottom!

QuikClot

For an extremity bleed, you use a tourniquet. What about a junctional bleed, like the neck, shoulder, armpit, or groin? None of these areas are amendable to tourniquet use. (SWAT-T tourniquets can be used to come up with some very effective pressure dressings for these wounds, but please notice the term “PRESSURE DRESSING” not tourniquet.) This is where quikclot comes in.

The newest generation is Kaolin clay impregnated. The clay absorbs the liquid in blood, concentrating clotting factors. A couple of points about QuikClot first. It is not a magic bullet. It is an improvement over regular gauze, but it still requires proper packing and direct pressure for at least three minutes, and then hopefully a pressure dressing will work. It cannot magically overcome the laws of physics. Hemostatic gauze is the one exception to unpacking a wound as well. If after three minutes, bleeding is not stopped, you may unpack the wound and repack with a second hemostatic gauze to get more medicine to the bleeding site. If you do not have a second hemostatic gauze, leave the first in place and continue to pack on top as normal.

You want to purchase the gauze, not the sponge. In order to work, the medicine has to reach the bleeding site. Think about a wound as an open bottle of soda. The sponge is going to get slapped on top as a lid, and in addition to not putting the medicine where it needs to be, no pressure is on the actual site of the bleeding. Now picture the gauze being packed into the bottle through the top, and the difference becomes clear. In addition to medicine delivery to the right place, the gauze helps pressure reach the bleeding site as well. The gauze also allows easy unpacking in surgery. With bleeding wounds, people think about indirect pressure– folding up a towel and using your whole hand to apply pressure. Very good results (especially on deeper wounds) are seen with two finger direct pressure applied directly to the bleeding site. Next time you have a cut, try applying pressure with your palm and then your thumb, and see which is more effective.

When packing a wound, you want to feed gauze with one hand and keep as constant pressure as you can with the fingers on the other hand on the bleed. QuikClot has some excellent videos regarding this on their website (see below).

The only hemostatic agents that TC3 recommends are QuikClot gauze and the new Celox gauze. If you cannot afford QuikClot, compressed or ”Z fold” gauze is an excellent second choice. The military tests included inflicting actual wounds on the femoral arteries on pigs, then the application of different types of gauze to try to treat the wound. Regular gauze was the second most effective behind QuikClot in these tests. (The newer celox gauze was not tested in this series.)

Realize hemostatic agents are rarely necessary to stop a bleed. Most (almost all!) bleeds can be controlled with gauze and pressure eventually. What hemostatic agents do is give you a greater margin of error in technique and application, and they help stop the bleeding faster. Don’t get caught up and rush out to buy a case of QuikClot, thinking it will solve everything if you are just starting out with medical supplies and training.. For the $20-30 to purchase one pack of QuikClot, you can buy 20 packs of compressed gauze, which will go a lot further towards your group’s medical needs and wound care. If you can afford it though, two or three packs per person is probably worth it. You can also find packs on eBay. I have confirmed with a rep that as long as the vacuum seal is intact, the product is still good past expiration date.

For training, we constructed some cheap wound packer aids. We took a small Tupperware container (Deeper than wide) and drilled a hole in the side at the bottom. We threaded a 20 gauge IV catheter through the hole, and used a silicone bead to hold it in place. You can attach an IV line, and set the bag to run at a drip rate. With enough gauze and pressure in the container as you pack it like a wound, you can tamponade off the flow, as visible in the drip chamber. We used an old CPR mannequin face to cover the container, with the mouth as the wound, so it has a flesh type feel. Cheap, but effective.

For pressure dressing, I prefer Israeli style ones with the pressure bar over the ”Bloodstopper” gauze roll variety. I think they will apply more pressure and are easier to apply. Whatever pressure dressing you buy (I like the standard gray vacuum packed ones), buy extra to open and train with. Try them in the dark.

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