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JWR,
I’ve just done First Responder training because the school I go to, a good one, won’t let me jump right into EMT training without taking First Responder first. A gold-digging measure? You decide! I think it may be, but it’s a good policy too.

I urge your readers to take a First Responder, a.k.a. CPR + Advanced First Aid. My course was $300. A cheapie way to do this would be to go on Amazon and get the book, but I highly urge a course. I plan to do EMT-1 then EMT-P and don’t expect to get paid for EMT-ing. We’ll be in full on collapse in a year or two, and it’s not about the money.

The thing is, there are nuances to medical care. You don’t just put a Vaseline-covered bandage on a sucking chest wound, you put an airtight bandage on, Vaseline on gauze or a piece of T-shirt’s one way, but the nuance is, a piece of plastic is fine, but it has to be set up to work like a flapper valve, taped down on three sides. For a tension pneumothorax, you use a “big” needle, what’s “big”? 12 gauge is a good idea, but there’s also a way you draw the skin down because there’s a vein that runs down along each rib and you need to miss that.

The thing is, I hope the article you published makes people want to go out and get training not just go, “OK, I read about this on the Internet once…” Beans, bullets, band-aids, and books, my friend.- Alex

Mr. Rawles,
The “The Tactical Combat Casualty” article was great. The reason Cowpuncher can’t get rofecoxib (brand name Vioxx) is that it was withdrawn from the market in 2004 by its maker due to claims of heightened rates of heart attacks compared to similar drugs like Celebrex). Rofecoxib was a new generation NSAID (like ibuprofen). Their claim to fame was that it caused less GI upset. It was a great pain drug but not much more so than regular 600mg or 800mg Ibuprofen or naproxen 500mg. There is a “class” effect of analgesia of drugs in this class so all are very similar in the right dose. In addition, rofecoxib was a lot more expensive (as is Celebrex). I am both a practicing physician assistant and family nurse practitioner 30 years in general medicine. Greatly appreciate your work. I am slowly winning my wife and four grown sons into the survivalist boat, but it is a slow process. Thanks. – R.P.

Jim:
Excellent post by Cowpuncher. I think too few people realize that we are talking about a two-way firing range here. I have had long discussions about this with my survivalist friends and the consensus is until we get some kind of medical professional into our group, it’s in the hands of God. We can carry tourniquets (“TKs”) and pressure bandages, along with faith, and drive on. Kinda emphasizes the importance of having someone in your group that can handle gunshot wounds. And keeping low profile, out of situations where you are being shot at.

A key point that I’d like to emphasize again is that you must be thinking about self-aid as much as possible. If you are hit, you have to try to treat yourself, and stay in the fight. With the small numbers we are talking about, we need every gun in the fight. My buddy, another SF dude, says they carry several TK’s on their kit and train to throw one on quickly and keep fighting. This goes to combat mindset, in that you must try not to shut down because you’re hit. I know, it is easy say, hard do.

I also like the TR “Ventilated Operator Kit” (VOK). Probably one of the best priced, most complete gunshot wound kits on the market. It’s one of the only places I know of that includes a de-comp catheter/needle.

Also worth mentioning is the “Olaes” pressure bandage by Tac Medical Solutions. Made by 2 former 18-Deltas, it includes a pressure bandage, with extra crilex that you can pull out to dress the other side of the wound, and has a piece of plastic that pulls out if you need an occlusive dressing. All in one package.

And finally, also from TMS, I carry the “SF” tourniquet, which is the black nylon one with metal windlass.

I have combined the de-comp needle and NPA from the VOK, with 2 Olaes Bandages, and TK from TMS for my gunshot wound kits. Since I carry pretty much around the clock, at work as well as at home, I keep a kit with me at all times. S/F – Diz

JWR,
The National Institute of Alcohol Abuse and Alcoholism notes that liver damage may occur with as little as 2.6 grams of acetaminophen (four to five “extra-strength” pills) taken over the course of the day in persons consuming varying amounts of alcohol (NIAAA, Seeff). The damage caused by alcohol-acetaminophen interaction is more likely to occur when acetaminophen is taken after, rather than before, the alcohol has been metabolized.

This liver damage is so serious it leads to the need for liver transplants. Since 1998, the Food and Drug Administration in the United States has required a specific warning on labels about acetaminophen. That warning reads: “Alcohol Warning: If you consume three or more alcoholic drinks every day, ask your doctor whether you should take acetaminophen or other pain relievers/fever reducers. Acetaminophen may cause liver damage.” Thanks, – Jacketch

The SurvivalBlog thread on wound-clotting agents got me thinking about this subject and its apparent lack of dissemination amongst the “survivalist” community. I decided I would write about it. I know the recent military vets will probably have heard about it, and some (most) will have practiced it. Many will have used it in action.

For the record, I received Tactical Combat Casualty Care (TCCC or TC3) training in the beginning of the program, so any new information I have gleaned since 2002 is based on studying the protocols as presented in the SOF Medical Handbook and the Ranger Medics Handbook that have been published in the last three years. Prior to that, I was combat lifesaver qualified in 1994 and 1996, and received my EMT-I license in 1997 which has since not been renewed. Eventually I intend to get my EMT-P.

The TC3 program began in the late 1990s under the auspices of the U.S. Navy’s Medical Bureau for combat first-aid training for special warfare units like the SEALs. It quickly spread throughout USSOCOM and then to the rest of the military from there.

The TC3 is broken down into three areas, or phases, of care. These are Care Under Fire (CUF), Tactical Field Care (TFC) , and Combat Casualty Evacuation (CASEVAC) Care. I will discuss the first two, since the third is largely the provence of actual medical doctors and surgeons and is beyond my area of expertise.

1) Care Under Fire

The underlying tenet of the CUF phase is that, if you’re being shot at, your focus should be on killing the enemy, not playing doctor. The only real concerns at this point should be returning effective fire at the ABC-type exam as is usually taught in civilian first-aid courses is not conducive to the continued survival of either the casualty, the medic, or the rest of the unit at this time.

If the casualty is capable of continuing the fight, he should be fighting, not worrying about his boo-boo. It may also be critical for the medic or corpsman to continue to engage the enemy. The following quote, from a doctrinal publication on the subject, refers to this need.

“It may also be necessary for the combat medic or corpsman to help suppress hostile fire before attempting to provide care. This can be especially true in small-unit operations where friendly firepower is limited and every man’s weapon may be needed to prevail.” (Emphasis added-a survivalist group certainly falls under that category!)

If hostile fire is not immediately suppressed, it may be necessary to move the casualty to cover though. One of the critical elements of TC3 training then is the importance of expedient casualty transport.

The Basic Management Plan for Care Under Fire looks like this:

1) Expect the casualty to remain engaged as a combatant if appropriate.

2) Return fire as directed or required.

3) Try to avoid being shot yourself (for the medic/aidman/corpsman)

4) Try to prevent the casualty from sustaining further wounds (move him out of the line of fire if he is unable to do so himself.).

5) Defer worrying about airway management tasks until after the fight. (The risk of the casualty choking to death on his own blood or teeth is significantly less than the risk that he will die if the unit is overrun by the enemy. Worry about killing the enemy first.)

6) Stop any life-threatening hemorrhage. Don’t worry about cuts and scrapes (or flesh wounds—said in best Monty Python voice). All wounds should be dressed with a simple pressure dressing initially (I like the Israeli Battlefield Dressings that are issued). If that is insufficient to stop the blood-loss, then wounds on the torso should have a HemCon agent applied, while wounds to the extremities are treated with a tourniquet.

7) Communicate with the casualty throughout the treatment process. Offer reassurance and encouragement (note to self—“Suck it up p**sy!” is not reassurance or encouragement). Explain the actions you are taking (this serves the double purpose of reassuring the casualty and allowing you to remember the proper course of action without skipping anything critical.).

8) Direct the casualty to return to the fight once treatment is “complete,” if this is possible and/or necessary.

Pretty self-explanatory, right? In the middle of the fight, the only concerns should be, finishing the fight, stopping life-threatening blood-loss, and keeping anyone else from being wounded.

2) Tactical Field Care

The first thing to look for in the Tactical Field Care phase is an altered mental state. An armed combatant with an altered mental state is a serious risk to others in his unit if he should employ the weapon inappropriately (such as mistaking the platoon leader for an enemy soldier/combatant…). He should be disarmed immediately.

Under field conditions, there are four primary causes for an altered mental state. These include Traumatic Brain Injury (TBI), pain, shock (possibly from blood-loss or simple emotional shock), and analgesic pain medication.

The Tactical Field Care phase is relegated to situation requiring medical attention, under field conditions, when there is no direct threat from enemy fire. Whether during patrolling missions, in a mission-support site, or following the cessation of hostilities on the battlefield, the Tactical Field Care takes over when the bullets are not flying.

As such, for the survivalist, the Tactical Field Care (TFC) phase will be the most commonly applied medical protocol if the TC3 program is adopted as a group’s standard for medical training (a course of action which I highly recommend).

The Basic Management Plan for the Tactical Field Care Phase

1) Casualties with an altered mental state should be disarmed immediately.

2) Airway Management

a) Unconscious without airway obstruction: (i.e. knocked out)

· Chin-lift or jaw-thrust maneuver as taught in standard first-aid courses

· Nasopharyngeal Airway should be inserted if the chin-lift and jaw-tilt are insufficient. (I have discussed this with both an attorney and a medical doctor. Both have assured me that because NPAs fall under Airway Management and are not surgical procedures that, as long as you have been trained in their application, such use is covered under the “Good Samaritan Laws” of most states. I know it is in Wyoming, Montana, Idaho, and Utah.)

· Place the casualty in a recovery position, as taught in standard first-aid courses.

b) Conscious or Unconscious Casualty with an airway obstruction or an impending airway obstruction (i.e. he got shot in the jaw or mouth and cannot breath through the mouth, throat is crushed, etc):

· Chin-Lift or Jaw-Thrust maneuver as above.

· Nasopharyngeal Airway as above.

· Place casualty in recovery position as above.

· If these are insufficient, a surgical cricothyroidotomy may be indicated, (using a local anesthetic such as lidocaine, if the casualty is conscious). This would fall under the category of a surgical procedure and would not be protected under the “Good Samaritan Laws” even if you received specific training on it during a military TC3 course of instruction. As such, I cannot recommend it as a course of action for survivalists in any but TEOTWAWKI-type situations. However, I will tell you that if it were someone I cared about, in the sort of environment I am typically in, such as 90 miles from town, down a snow-covered gravel or dirt road, and I knew that a surgical “cric” was going to save their life….I’d do the cric. That having been said though, I’ve had numerous classes on the procedure and know how. I would still feel uncomfortable though.

3) Breathing

· Be aware of the risk of a tension pnuemothorax if the casualty has suffered from a trauma injury to the torso and is in respiratory distress. If a tension pneumothorax occurs, treat with a needle thoracostomy, also known as a “chest punch,” (No, it does not involve striking the casualty with your closed fist.)This also involves a surgical procedure and is not protected under the “Good Samaritan Law” even if you received proper formal training during a military TC3 course. The same issues apply to it (across the board) as to the surgical cric.

· Treat sucking chest wounds with a Vaseline-treated gauze dressing, covered with tape. Place the casualty in a seated position and monitor for tension pneumothorax.

4) Bleeding

· Assess the casualty for previously undiscovered hemorrhage and treat any unresolved bleeding injuries.

· Assess for the discontinuation of tourniquet treatments following the application of a HemCon agent and/or pressure dressings.

5) Intravenous Therapy

· Start an 18-gauge IV/saline lock if indicated.

6) Fluid Resuscitation

· Assess for hemorrhagic shock ( altered mental state in the absence of a head injury, and/or weak or absent peripheral pulse along the radial artery are the best field expedient indicators of hemorrhagic shock).

a) If the casualty does not appear to be in shock, no IV fluid resuscitation is indicated. Instead, provide fluids orally if thirst is indicated by the patient.

b) If the casualty is in shock, the .mil response is a 500mL bolus of Hextend, then repeat after 30 minutes if the casualty is still in shock. The doctrinal literature indicates that you should not provide more than 1000mL of Hextend under field conditions. For the survivalist unable to procure Hextend, saline solution or a lactated Ringer’s solution may be an adequate alternative, since both were used prior to the introduction of Hextend into the military care program.

· Continued efforts towards fluid resuscitation must be considered in light of the logistical and tactical concerns of the risk of further casualties when continuing the mission. In other words, don’t waste IV fluid if you don’t think you’re going to be able to save the casualty, because you might need them later for someone who can be saved!

· If a casualty with TBI has no peripheral pulse (but does display a carotid pulse), resuscitate with IV fluids to restore the peripheral pulse.

7) Dress all known wounds with appropriate bandaging. This is an opportunity to remove HemCon agents and/or pressure dressings and tourniquets, in order to care for the wounds with more reliable semi-permanent dressings that may be required to stay in place for an extended duration. Check for additional, previously undiscovered wounds and injuries at this time as well.

8) Provide analgesia pain relief as necessary and available. (Note: providing medication to someone is called “practicing medicine without a license.” It is severely frowned upon by the medical professions, the court systems, and if you do so, you may be setting yourself up for serious legal problems, including imprisonment. Forewarned is forearmed. It may also be frowned upon by the casualty if you provide the wrong medication and they die from it, just sayin’…)

a) If the casualty is capable of continuing the mission and/or fight, the doctrinal response (in my literature, it may have changed recently, do your research) is 50mg of Rofecoxib by mouth and 1000mg of Acetaminophen by mouth, every six hours. Since I do not have access to Rofecoxib, I have discussed the issue with several Special Forces Medics, two SF-qualified physician’s assistants, and three civilian medical doctors. Their unanimous response was, “Give them the Acetaminophen and a couple shots of whiskey. It’ll do.” Thus, my non-TEOTWAWKI solution is just that. Be forewarned however, that alcohol will thin the blood, so individuals with significant blood loss should be provided whiskey only under the strictest of circumstances, if at all. In a TEOTWAWKI-type scenario, I believe I MAY be able to procure Rofecoxib or a similar suitable analgesic if I move quickly and surely.

b) If the casualty is unable to continue the mission, the doctrinal answer for the .mil is to provide 5mg of morphine intravenously, and reassess in ten minutes. Continue providing the same dose every 10 minutes, as necessary to control pain, until the casualty is exfiltrated. Assess for respiratory distress . Treat further with Promethazine, 25mg intravenously or intramuscularly, very four hours. Since there is no way in Hell I can legally procure morphine, I am currently unequipped to provide this portion of care. Should TEOTWAWKI occur, I will either procure morphine immediately, from a pharmacy, or I will procure a similar opium-based product that is regularly available in this country without a medical license (yes, I’m talking about heroin, which will probably still be available…) Please note that I am not, in any way, shape, or form, advocating armed robbery of a pharmacy, even in TEOTWAWKI. I know of three or four licensed pharmacists that have assured me, in the event of a TEOTWAWKI-type of collapse, they would much rather provide me the pharmaceuticals I need/want than have them fall into the hands of recreational drug addicts. The discussion of possible barter, should that occur has already taken place.

9) Splint any fractured bones and recheck pulse. Pretty self-explanatory, although I will note the following. While I do have the knowledge and equipment to improvise splints in the event of a severe medical emergency, my aid bag contains several (five at last inspection) SAM splints. These are a valuable tool that I recommend every survivalist include in their aid bag. It beats the holy living hell out of trying to scrounge up an improvised, field-expedient solution in the midst of an emergency.

10) Prophylactic antibiotic treatment is recommended for all open combat wounds. Even if your bandages and dressings are sterile, I can assure you, neither the surface of the casualties skin, his clothing, or the injury-causing instrument were sterile. Treat any open wounds as infected.

· The latest manuscript I have that recommends a specific antibiotic, indicates Gatifoxacin by mouth (400mg daily).

· If the casualty is unable to take the Gatifoxacin orally, the doctrine calls for a slow push over the course of 3-4 minutes of 2g of cefotetan intravenously, or intramuscularly. Again, I don’t currently have access to these, and disbursing medicine is practicing medicine without a license. However, I have in the past, treated myself with prophylactic antibiotic, using Penicillin G intramuscularly with no ill effects. There is a long history of self-aid amongst agricultural workers in the U.S. using medications packaged for veterinary supply. That may be a reliable source of antibiotics for survivalists, as Ragnar Benson points out in several of his books, including “The Survivalist’s Medicine Chest” and “Do-It-Yourself Medicine.” If this is a course of action you choose to follow, make sure you do your research prior to needing to apply it! For instance, LA-200 is a common antibiotic provided to cattle intramuscularly. Unfortunately, it is an oil-based medication and has been known to cause severe side-effects in humans…So, know your meds and know what you are providing!

11) Communicate with the Patient. The same principles apply regarding this as in the CUF phase. Talk your way through every thing you do. It will assist you in getting it right.

12) Cardiopulmonary Resuscitation. I suggest that everyone should complete an updated CPR program, as provided by the American Heart Association and/or the American Red Cross. You are far more likely to utilize your medical aid training and knowledge during run-of-the-mill daily activities than you are to provide the TC3 level of care. That having been said, I feel obligated to include the last bit of information in my literature regarding CPR. “Resuscitation on the battlefield for victims of blast or penetrating trauma who have no pulse, no ventilations, and no other signs of life will not be successful and should not be attempted.” While this does not exempt you from the moral obligation to provide aid in daily life, pre-WTSHTF, it may be sensible to consider the implications of that statement when dealing with triage during major accidents and calamities, such as multiple vehicle accidents and/or terrorist attacks/active shooter situations.

For survivalists interested in further TC3 training, several of the major shooting schools, such as Tactical Response and Gunsite (I believe), offer Tactical Medicine courses for non-medical personnel, which rely heavily on the TC3 protocols.

For those interested in developing or purchasing a TC3-type aid bag or blow-out kit, there are several companies manufacturing them. I am personally fond of Tactical Response Gear’s Ventilated