Traumatic Tension Pneumothorax And Your IFAK

 As promised/requested:

From Comments on an unrelated post last week, I was referred to, and requested to comment on, a specific medical advice post at The Firearms Blog:

Which we'll get to momentarily.

But first, let's review a few things, to set the table for the discussion that follows.

I. Tactical Combat Casualty Care

TCCC was originally developed jointly by SF Medical and NSW (Army Green Beret and Navy SEAL medics, for civilian pogues), by both their team medics and medical staff, shortly after Gulf War I and before Gulf War II and A-stan operations, and was rolled out as a military SOF medical course. The original concept was to identify the most frequent causes of combat deaths that could be reduced by timely field treatment by field medical personnel, with minimal additional gear. Massive hemorrhage, airway occlusion, sucking chest wounds, tension pneumothorax, IV access/fluid resuscitation, and hypothermia/shock prevention were identified as the biggest payoffs in treatment for the least outlay in training and medical resources. The information, once disseminated among SF, was deemed far too good to restrict to just the high-speed low-drag types, and well within the scope of ordinary medics, and even average troops, and was subsequently adopted military-wide, and then by civilian elements, starting with law enforcement tactical teams, and from there, on to ordinary paramedics, EMTs, and trauma specialists throughout the civilian world. There are currently 42 voting members on the Committee on TCCC, who decide upon and frequently revise the TCCC guidelines, and they represent deployed specialists and doctors from all service branches. It has been regularly updated, and rigorously field-proven in practice in two decades of warfare in SWAsia in Iraq and Afghanistan. Its adoption and promulgation on a widespread basis resulted in a phenomenal and unprecedented reduction in killed-in-action deaths, casualties who died of wounds, and preventable combat deaths. You could look it up. In short, this is evidence-based trauma practice from the pointiest tip of the sh*tty end of the stick, not just a couple of guys just spitballing what-ifs and pulling stuff out of their ass.

Covering all of TCCC is beyond the scope of this post, but we've done so in the past in abbreviated form, 

TCCC I: Care Under Fire

TCCC II: Tactical Field Care

TCCC III: Tactical Casualty Evacuation

along with some other perennially needful things, and you should be familiar with it if you're in the military, own guns, or simply might get jacked up by some miscreant or random injury. In short, if you have a pulse, the nuts and bolts of TCCC should concern you deeply and personally.

For your edification, if you haven't already done so, you can (and should) download the entire current TCCC course free from the following link:

TCCC Guidelines - Nov 2020 ed.

Then read it, assemble the toys, watch the videos, and practice the skills, until they become second nature.

The military course for every Larry Lunchmeat (TCCC-ASM) in the dot-Mil is a total of 7 hours. 

The Combat Lifesaver course (TCCC-CLS) is 40 hours, geared for previously non-medical personnel.

The course for actual medical personnel course (TCCC-MP) is 16 hours.

None of those should kick anybody's ass to master, but it's your ass, and your time, so either learn it, or suture self.

II. Your IFAK Blow-Out Kit

The TCCC items that should be in your Individual First Aid Kit - IFAK (or elsewhere in your gear) would be: 

* a modern tourniquet (CAT-T or SOF-T recommended) - ideally as many as you have limbs, unless you figure you won't really need all of yours. At least one of them should be in the actual IFAK. The others can be anywhere in your gear. But if you think you need less, you're simply wrong, unless one or more of your limbs are already prosthetic. End of discussion.

* Any one of 57 varieties of clotting gauze and Israeli Bandage compression dressing(s)

* a  nasopharyngeal airway (AKA "nose hose") kit

* an occlusive chest seal (or actually, two, as many penetrating wounds tend to leave entry and exit wounds; or even more, as sometimes, you have more than one wound, or may be caring for more than one person)

* a chest decompression needle - or really, two to four, since it may take two pokes, and you have two lungs. (which item(s) is/are exactly the point at issue today)

* [for those for whom it's within their scope of practice and/or expertise, a cricothyrotomy kit, IV start kit, and appropriate IV supplies and antibiotics (that will be "NOT YOU" for 95% of readers here, so we ain't gonna cover any of that here)]

* a mylar casualty blanket (including a hypothermia headcap, if possible/necessary)

If you haven't got an IFAK that contains at least 6 of those 10 items already, you're just wrong.

And now, a few words about why this is germane today.

III. Tension Pneumothorax

First, basic lung anatomy:

Your lungs reside inside the pleural cavity (your chest), and they work as a bag-within-a-bag on each side (so our lungs don't rub up against your chest wall every time you breathe).

There are multiple non-traumatic causes for a pneumothorax, but we're only concerned today with the traumatic ones: penetrating or blunt, e.g. by gunshot wound(s) (GSW), explosive fragmentation, stabbing, one or more rib fractures, or blunt force (beating, motor vehicle accident, fall, explosive blast trauma, etc.). When something traumatically punches a hole (or holes) in your meat suit above the diaphragm, air can leak out of the inner sac (the lung) and enter the pleural cavity (the bags that the lungs sit in). This air is trapped, and cannot escape, and as more air gets inside the pleural cavity than inside the lung, the lung collapses. 

1. Besides the original trauma, this hurts. A lot.

2. It cuts down on your ability to transfer oxygen in and CO2 out. This gets worse by the breath, due to the ongoing hole.

3. This makes you breathe faster (tachypnea). Normal adult respiratory rate is between 12-20 breaths a minute. Anything over 20, by definition, is tachypnea.

4. Which makes your heart beat faster (tachycardia). Normal cardiac rate is 60-100 beats per minute. Anything over 100, by definition, is tachycardia.

5. This makes you feel short of breath (dyspnea), and somewhere between uneasy and full-on panicky. The worse you are, the worse this gets. This, in the immortal observation of Cliff Clavin, is called a "vicious circle".

6. As the punctured lung collapses, it pulls your trachea (windpipe) to the good side, pressing on the pericardial sac (where your heart lives). Which makes it have to work harder, which makes it beat faster, while oxygen transfer isn't occurring in 50% or more (your lungs are different sizes) of your respiratory tract, which makes it beat faster, and get behind, which backs blood up into your heart, which makes it beat faster, which makes blood back up upstream, especially coming down from your brain, which makes your jugular veins bigger on both sides. Which makes you more panicky, and more short of breath, and you can see the patient's trachea go from midline, and move over to the good side (tracheal shift). Meanwhile, your heart is not working properly, leading to low blood pressure (hypotension), and low oxygen exchange body-wide (hypoxia), and you're going into shock. See how one hole makes everything go to shit in a hurry?

Here it is in pictures, and a basic video:

Turn the volume off; there's no narration.

That should cover it, and anything simpler would require crayons. 

Now, we get to the rat-killing:

IV. The Post In Question

Ask Doc: Please Stop Carrying Chest Darts

I will adopt the format used by The Other Ryan, from his sadly departed blog, Total Survivalist Libertarian Rantfest, to wit:

A. The Good

That giant three-and-a-half-inch, 14 gauge needle is colloquially known as a “chest dart”, but is more appropriately a tool used to perform a needle thoracostomy to decompress overpressure from a tension pneumothorax (we will refer to this in shorthand as tPTX). First off, if you could not immediately define a tPTX per the last part of that previous sentence, that may be an indication that you have no business carrying that equipment.

Absolutely SPOT. ON. If there's anything in your kit you don't know WTF or HTF to use, either unf**k yourself, or get it out of your kit. There is no third option.

And then, after this certified brilliant observation, he goes into the guard rails.

B. The Bad

"A tPTX takes a long time to develop—like 30-40 plus minutes (even up to hours). Using signs like “tracheal deviation” and “jugular vein distention” means you missed the problem a long time ago. By the time you start having vital sign changes and cardiac problems, the condition is pretty progressed, and is also what makes it “tension”. The tension is what is causing the vital sign changes since unacceptable pressure is being applied to the heart and vascular structures."

Sorry, Slick, but no, it doesn't take a long time. It takes as long as it takes. Bigger holes make it happen faster. File this under Physics, and Duh! It can happen in as little as a few minutes after the injury, in fact. BTDT. Teenager with one punch from a 9mm, walked in under his own power, already in extremis after maybe 5-10 minutes, affected side had a partially collapsed lung. Chest tubed immediately. Oxygen sats immediately jumped from the high 80s to the high 90s. Don't have a trauma physician, Rx meds, wall suction, and a chest tube kit the size of a daypack? Might be a good idea to have a large-bore chest decompression needle then, wouldn't it?

"There are a few vital signs that may indicate a tPTX. Hypotension, hypoxia, subcutaneous emphysema, and tachycardia. For hypotension, you need to measure the blood pressure which means a blood pressure cuff and hopefully a stethoscope. For hypoxia, you really need a pulse oximeter (though cyanosis could be argued if you can rule out other causes). Tachycardia is easy to measure (and the pulse oximeter will do this for you as well).

Alongside that needle, do you also carry a stethoscope, blood pressure cuff, and pulse oximeter, in your IFAK?"

If you're the designated medic, you damned well better carry those items, and know how to use them. If, instead, we're going to use the most lazy and the stupid as the average person, the argument to dump gear becomes endless, and ends with the advice to simply suck your thump and hug your teddy, because anything else is out of your lane.

But c'mon, Doc, let's stop being stupid. I can diagnose tachycardia with one finger on a pulse, and a cheap Timex, in about 6 seconds. Even under the fireworks show at Disneyland, let alone in combat. I can use a calibrated eyeball and that same watch to diagnose tachypnea, same method: count for 6 seconds, multiply by 10. This is retard-simple. And while a pulse oximeter is fabulous for hypoxia, the most sensitive organ in the entire human body is the brain. If the patient is becoming more anxious, is diaphoretic (sweaty), and getting panicky, it's probably hypoxia and hypotension. Blue lips and extremities are worse, but even more simple, except at night. And if I can't find a pulse at the wrist, systolic pressure is below 80. If I can't find one at the groin/pelvic junction, it's less than 70. If I can't find one at the carotids, it's time to start CPR. I can tell all of that in about 2 seconds, with no BP cuff, and we both know none of this is news to you. One can piss and moan about ultimate accuracy, but if your standard of care is a fully equipped ER or nothing, why have a medical kit at all? That's a "shoot the wounded, and drive on" standard of care. So stop acting like this is Chinese calculus.

The indication for needle decompression in the field, far from CT, chest X-ray, or any other medical machinery, which is the whole point of TCCC, is if the patient is hemodynamically unstable. IOW, if they're breathing too fast, their heart rate is elevated above normal, their oxygen saturation is down, their blood pressure is dropping, or they have jugular venous distension (JVD) and/or tracheal shift. That's both WHEN and WHY you do needle decompression.

Telling me that needle decompression is bad because some people do it too often, too poorly, and/or too soon, means they don't understand that whole "clinical indications for therapy" part of the lesson, and/or haven't mastered the basic skill. That's a bad instructor/stupid medic problem, not a bad emergency technique problem.

C. The Ugly

"I would argue that someone that has the appropriate experience and training to CORRECTLY diagnose and decompress a tension pneumothorax, happens to be there at the exact time you need it, is willing to do the procedure knowing that they know will likely NOT be covered by insurance (or Good Samaritan laws), and also doesn’t have their own equipment is a Venn diagram of “not going to happen”.

Venn diagram I poorly drew showing the above scenario…

Or maybe you are running around the downtown of a large urban area (while wearing your plate carrier and carrying your IFAK) and a mass casualty occurs. Assuming you haven’t been detained by the authorities for looking out of place (unless there was an airsoft gear convention going on), you hop in and start helping. Nearby someone yells out that “I’ve got a tension pneumo here; anyone have a dart?”. Your cape unfurls, you rip open that IFAK, and chuck over that needle.

Tongue and cheek, yes, but seriously… Think through what actual scenarios you are likely to encounter and the probability of having a patient that will develop a tension pneumothorax and having another Good Samaritan on hand that can fix the problem."

Okay, that's the Captain Recockulous Strawman Version. Now, how about if I play?

i. Dumbass at the shooting range muzzle sweeps the line, and dumps a round into the guy two lanes over from you. After observing some other guy helpfully remove the pistol from Dumbass' hand and punch the shit out of him by way of getting his attention, you notice the guy on the ground has frothy bubbles of blood forming around that shiny new hole in his chest, and he's having some trouble catching his breath. But it's okay, you're out of cell service, it's only a five-minute run to the range shack phone landline, and the range is only 40 minutes from civilization. Think you might need a chest needle there, Butch?

ii. You're driving any one of a hundred lonely highways in BFE west of the Mississippi, and you're the first one to come upon the scene of an automobile accident, and you find the driver of the older car minus airbags somewhat the worse for wear, with a lot of chest pain, blue lips, sore ribs on one side from that steering wheel he slammed into when he hit the ditch, and his trachea is pointing to one side. Hmmm, good thing you left your tools at home because someone told you you'd never need them, right?

iii. Hiking with your friends, Jimmy takes a tumble down a slope, but fortunately, a large boulder to the chest arrests his further ass-over-heels progress after only 50-80 yards of tumbling. When you get down to him, he's panting for breath, he can barely talk, and he's got a lot of pain in the ribs on that side. What can the matter be?

Traumatic TPT doesn't require the Marines clearing Fallujah of dug-in Taliban to happen. Pretending otherwise is idiotic, or one has led a very sheltered life in trauma care.

And someone who acts according to the standard of a "reasonable person", within their level of training, is going to be completely covered under Good Samaritan laws in 50 states and seven US territories, just like with CPR or basic first aid. That doesn't mean you can't be sued, it means they can't win. In fact, failure to act may be prosecuted as criminal negligence if it was an accident you had a hand in accomplishing (like an auto collision), because at that point, you have an affirmative duty and legal obligation to render appropriate aid and summon help. Time and place are a factor, as is your level of training, and equipment available. The standard moves, depending on whether you're across the street from the fire station, or 50 miles out in the woods, two days' hike from the BFEgypt Community Hospital and Veterinary Clinic. So it depends on how much of a good guy (or douche) you are, at that point, and what's available for use.

"IT’S BETTER TO HAVE IT AND NOT NEED IT THAN NEED IT AND NOT HAVE IT…

I’d love a portable trauma suite fully staffed with trauma specialists, but the reality is…

In wilderness medicine, we discuss the concept of “Ideal vs Reality”. Ideally, I would like to have instant access to all of the specialized equipment I could and be able to deploy instantly as needed. The reality is that I can only carry a limited amount of stuff without looking like a crazy person (depending on the context) and drawing inappropriate attention. The reality is that I am likely to encounter only a small subset of known (and treatable) medical problems in normal life. 

100% of the people on the planet will experience cardiac arrest at least once. That doesn’t mean I carry an AED around with me everywhere.

I can think of many different things that would make my first aid kit long before a decompression needle. No one that has ever dealt with a traumatic medical emergency has ever said, “You know, I just had too much gauze available…”

Part of providing medical assistance is having good judgment. Good judgment includes understanding the injuries that are most likely to happen and having the ability to treat those injuries. Good judgment is also staying in your lane (within your training and experience).

IT DOESN’T TAKE ANY SPACE IN MY IFAK

You could fill an entire IFAK container with equipment that “doesn’t take any space”. Don’t let equipment serve the role of magic talismans that replace training and skills. The most important piece of equipment is your brain. Fill THAT with the ability to determine if a problem is serious or not serious and if the problem is getting better or worse.

In your IFAK, you should carry, at a minimum, tools to help you deal with IMMEDIATE life-threatening injuries. Injuries that will kill you right now. Tourniquets (a real tourniquet that applies mechanical advantage and is backed by science, not a fancy rubber band). Compressed gauze. Chest seals. Be wary of any kit that does not include those items."

Let's stop bullshitting here, Doc: chest decompression needles are the size of ink pens, and of similar weight. We're not talking about packing a CT scanner in your pack, or leaving behind the tourniquets and all the bandage gauze. Four of them take up minimal space, and weigh maybe 4 ounces. This is stupid easy and simple, for field reversal a simple but treatable life-threatening condition, which is the whole point of all of TCCC. And if you don't do it, they're probably just going to die. I vaguely recall in school hearing that that's bad, but I'm open to counter-discussion on that.

Tension pneumothorax is both life-threatening left untreated, and reversible with minimal equipment and training. And there's nothing else than can substitute for that chest decompression needle if you need it RFN. Many of us carry three pounds of loaded handgun, holster, and spare mag or so, FFS, every time we leave the house, even though needing it is literally a one-in-a-million situation. You want to pull out your crystal ball and tell me when I won't need that, too?

We can go back and forth, and I can knock over all the straw men (and that's about 90% of the blogpost) you've built for why you're right, and all the king's horses, TCCC, the committees that developed it, and thousands of medics and trauma docs, military and civilian, who think carrying a chest needle is a good idea are all wrong. But forget anything I say. Let's just look at go-to medical thinking, from someone far above both our pay grades: the author(s) of an authoritative professional medical text:

A tension pneumothorax is a severe condition that results when air is trapped in the pleural space under positive pressure, displacing mediastinal structures, and compromising cardiopulmonary function. Early recognition of this condition is life-saving both outside the hospital and in modern ICU. Knowledge of necessary emergency thoracic decompression procedures are essential for all healthcare professionals. Traumatic and tension pneumothoraces are life-threatening and require immediate treatment.

Patients with trauma tend to have an associated pneumothorax or tension pneumothorax 20% of the time. In cases of severe chest trauma, there is an associated pneumothorax 50% of the time. The incidence of traumatic pneumothorax depends on the size and mechanism of the injury. A review of military deaths from thoracic trauma suggests that up to 5% of combat casualties with thoracic trauma have tension pneumothorax at the time of death.

...hypoxemia, acidosis, and decreased cardiac output [from tension pneumothorax] can lead to cardiac arrest and, ultimately, death if the tension pneumothorax is not managed in a timely fashion.

 On examination, it is essential to assess for signs of respiratory distress, including increased respiratory rate, dyspnea, and retractions. On lung auscultation, decreased or absent breath sounds on the ipsilateral side, reduced tactile fremitus, hyper-resonant percussion sounds, and possible asymmetrical lung expansion are suggestive of pneumothorax. Symptoms of tension pneumothorax are more severe. With tension pneumothorax, patients will have signs of hemodynamic instability with hypotension and tachycardia. Cyanosis and jugular venous distension can also be present. In severe cases or if the diagnosis was missed, patients can develop acute respiratory failure, and possibly cardiac arrest. In some instances, subcutaneous emphysema can also be seen. The diagnosis of tension pneumothorax must be made immediately through clinical assessment as waiting for imaging, if not readily available, may delay management and increase mortality.

Initial assessment to determine whether the patient is stable or unstable dictates further evaluation. Emergent needle decompression or chest tube thoracotomy must be performed immediately if the diagnosis [of tension pneumothorax] is highly suspected."

Gee, chief, that's gonna be kind of hard if you left all 2 ounces of those two chest needles back home, because you thought you'd never need them, i'n'it?

"Tension and traumatic pneumothoraces are usually managed in the emergency department or the intensive care unit. Management strategies depend on the hemodynamic stability of the patient. In any patient presenting with chest trauma, airway, breathing, and circulation should be assessed. Penetrating chest wounds must be covered with an airtight occlusive bandage and a clean plastic sheeting. 

If the patient is hemodynamically unstable and clinical suspicion is high for pneumothorax, then immediate needle decompression MUST be performed without delay. Needle decompression is done at the second intercostal space in the midclavicular line above the rib with an angio-catheter."

They sound pretty sure of themselves, don't they? But what do doctors and medical school professors know about this? Oh, besides all that medical school, and stuff...

Tom R. (the author of the offending post at The Firearm Blog) may be a helluva field medic. But his advice on this subject is tainted by advocacy with a dearth of authority or common sense behind it, and a surplus of logical fallacy and just plain silliness.

Should untrained Jaspers try needle decompression? Hell no!

If you're an idiot, or simply too lazy to learn the skills, by all means, leave out the chest needles. You don't need them, for a certainty. If the audience at The Firearms Blog is a bunch of lazy idiots, then the post is solid gold sound advice. I don't know them, so I cannot say.

If you're not an idiot, and you're going to pack the gear, you'd better damned well know the pathophysiology of this cold, understand the correct procedure (which we have not gone into in depth here, but which takes less than 3½ minutes to learn), have practiced and demonstrated same correctly under competent training and preceptors, and be able to explain in excruciating detail why you did or didn't do it multiple times in a court of law afterwards.

Stabbing someone in the chest is a lot like shooting people, in that respect. You're going to be talking about it afterwards, and not in a comfortable "There-I-was" way. Bet. On. That.

But the medical literature - nearly all of it - is 180° out from Tom R.'s dubious advice. You're packing your own kit, and neither he nor I are holding your hand when you do that. You're going to have to use your own head (brains optional but highly recommended), and trust your gut. But as Murphy's Laws Of Combat informed you, "Anything you do, including nothing, can get you or someone else killed".

But if you need to do it, in either the case of shooting someone, or needle decompression, explaining that you left the gear home because someone on the internet told you that you'd never need it isn't going to help much, and somebody is liable to suffer death or serious injury because of your lack of foresight.

If medical stuff is too hard for you, don't do it. You won't hurt my feelings. But if it's not, learn the things that can actually make a constructive difference, carry the gear to do them, practice the skills, regularly, and be prepared, intellectually and emotionally, to suck it up and do them if the need arises. Chest trauma is rare, but certainly not beyond the realm of possibility, even in everyday peacetime situations. And tension pneumothorax in the presence of chest trauma is pretty common, and the actual medical literature is clear: prevention of death is a lot easier on the patient if you don't wait until the last second, and they're in cardiac arrest, because you dithered. Suggesting that standard is flatly asinine, and contrary to every precept of trauma medicine. I'm going to go with that advice, and leave the advice found in this editorial turdburger right where I found it. Particularly when we're talking about carrying something the size and weight of ink pens.

If that's too much extra gear to carry, maybe skip the whole first aid kit, and just carry a rabbit's foot, right?

The author at TFB may have any number of good and well-thought out posts on medical advice for Joe Average. But the example referred to me is NOT one of those, and for the reasons set forth above, we consider it really, really bad advice. And if you look at his closing comments, it seems he knew from the outset he was jumping hard on his wedding tackle with cleats on, and expecting exactly the response I've given. One can only ask, "Then why do it?" For reasons passing understanding, some people are masochists, we suppose.

The whole post reviewed, on reflection, sounds exactly like the cinematic chin-wagging from gold-plated Ranger battalion geniuses who told Grimes in Blackhawk Down that he wasn't going to need water, NOD, or trauma plates(@01:32ff).

So, how'd that "wisdom" work out when tested?

Learn and live.

If anything in this left a mark on anyone, we commend to their usage a certain ointment.

Monday Medical: Wound Care

So you've got a wound to deal with; yours, or someone else's.

In order:

Expose the wound(s). Find them all. ALL of them.

Get all the clothes, debris, dirt, blood, etc. out of and away from it.
If you have to cut or rip clothes, do it now, and do it fast.
Strip 'em and flip 'em is the rule to follow.

These all work for that:

If they aren't in life-threatening danger, and you're not a dick, you can cut along seams, and through laces preferentially. Laces can be replaced cheaper than boot leather, and cutting on/along seams lets them sew a garment back to being intact with a lot less trouble.
Which might be a consideration if clothes and sewing machines are hard to come by.
If they are or could potentially be bleeding out, BE A DICK.
Tell them I said it was okay. 

Leave impaled objects where they are.

If there are objects impaled further into the wound than you can see, leave them alone.
Why?

November 14, 1990

TUCSON(AP) — An 8-year-old boy was listed in critical condition today after surgeons unscrewed a steel rod that pierced his body when he fell from a roof.
"He probably just thinks this is kind of a slight inconvenience in his life," trauma surgeon Dr. Michael Esser said of Justin Stiner, who asked for some ice and wanted to play Nintendo on Tuesday after waking up from surgery.
The 4-foot-long, 1/2-inch-thick threaded bar used to reinforce concrete was literally unscrewed from the boy's neck and torso Monday in a 2 1/2-hour operation at University Medical Center. Eighteen inches of the rod had penetrated his body.
Esser said that the heart wounds should heal fully and that, although the boy's severed jugular vein was tied off, other veins can provide the needed circulation. The jugular vein carries blood back from the head to the heart.  

The 4-foot-10, 86-pound third-grader from Sierra Vista fell onto the rod while playing with friends on the roof of a house Monday morning. He was suspended two feet off the ground for about 20 minutes, alert the whole time, while paramedics cut the rod, which pierced him just below the breastbone.

Justin, who was taken the 80 miles from Sierra Vista to Tucson by helicopter, neither panicked nor screamed, and on arrival "wanted to know if I was going to remove it. He was very cooperative," Dr. Phillip Richemont said.
Richemont said surgeons were stunned to find that the rod had pierced the heart in two places and divided the jugular vein. "But yet it didn't bleed. It's amazing," Richemont said.
During the operation, the heart seemingly "contracted down between the threads," cutting off bleeding, Richemont said.

The rod was a piece of rebar that he fell onto from his garden shed roof; grandma used it as a stake to coil the garden hose around. After penetrating into and out of the right ventricle of his heart, the rod severed the external jugular (IIRC) and then pinned it against his right clavicle. If it had been moved at all, he would have died from either wound. The paramedics on scene hand-sawed it off , packed it, and transported him to the hospital with it in place. He's 38 years old now instead of dead in his grandma's garden because of that move.

The piece of whatever impaled into the globe of an injured eye may be the only thing keeping the aqueous humor inside the globe. If someone is blind, you won't fix that, but if they aren't, you might create the problem. Leave things alone you can't fix. Splint them so they don't move or cause additional problems.

Clean and disinfect the wound(s).

The solution to pollution is dilution.
Which is a med school canard that means "irrigate all wounds until they bleed saline solution".
Clean tap water is your second choice for superficial wounds.
And the only way to get something clean is to get something else dirty.
True with cars, houses, and patients.  Saline, gauze, rags, etc. will be consumed out of all proportion to the wound. Get over it, and get it done.

For deep wounds, a solution of half sterile saline, and half povidone iodine {Betadine™}solution (not Scrub, which is a stronger and harsher liquid form) gets squirted under plunger pressure from a syringe (5-20cc) into the wound. Splash shields and safety goggles are your friend here, unless you want a faceful of bloody (or something worse, think abdominal wounds) backsplatter.
One blast isn't nearly enough. Keep going, then irrigate with just saline, then repeat, then repeat, then repeat, until you're sure you've gotten everything foreign out.

You can also do this with superficial injuries.

For small stuff, like cuts and scrapes, Bactine[tm] has both BZK (benzylkonium chloride, a relatively harmless disinfectant) and a small amount of lidocaine (which numbs pain).
Use it.
Not isopropyl alcohol, which is flammable, and only for sterilizing instruments.
Not hydrogen peroxide, which is only for getting blood out of clothes, carpet, and fabrics, not cleansing wounds. (Like moving a body before the cops get there, and tidying up...)
Both of the latter also burn like hell in fresh wounds, because they're killing healthy vital tissue, and they don't work well. Using them anyways may get you socked by your patient.
Or their lawyer.
After Bactine, clean tap water, or water you've made sterile by boiling (and cooling, please) is okay.

Water from the ocean, lake, river, stream, pond, or from your or the patient's canteen that's been backwashed in, absolutely not.

We either use sterile solutions, or holy water on wounds.
Holy water? How do I make holy water?
You boil the Hell out of it.

Stop serious bleeding.

Direct pressure.

Direct pressure and elevation.
Tourniquet (TQ).
Pressure points.
In that order, unless you're under fire (in which case, you use the TQ now, get back in the fight, then go back and re-address things after the shooting stops.)

Nota bene: And for deep bleeding wounds, esp. of the torso, this is what that Combat Gauze was made for: as an internal instant scab over large bleeding wounds (assuming you're evacuating your patient to higher care, where someone can surgically repair what you're putting a temporary packing against, which will be removed at a Battalion Aid Station or equivalent, or else in an OR). If that higher level of care is not an option, because Zombpocalypse, Combat Gauze just means they'll die from infection in a couple of days, instead of massive hemorrhage now.
Your call in that case. Just remember, death is final, either way.

Apply Magic Spackle.

By which, I mean products purposely made to keep wounds clean. And help kill germs.
Neosporin (triple antibiotic).
Polysporin (double antibiotic).
Bacitracin (single antibiotic).
Burn gel (for burns, if you have that).

Most of what's in these (like 98% for the first three) is just sterile petroleum jelly, to hold the antibiotic components (the other 2% or so) in stasis where you want them, next to the open wound.

If it doesn't have FDA drug information on it, the answer is generally "No."
In some cases, "F**k NO!"

("But can't you put honey on cuts? I read this outdoors nature manual where Sumdood from the Discovery Channel wrote...")
Yes, honey can work. It also works to attract bees. Flies. Ants. Cockroaches. Etc. While providing a potential growth medium for new bacteria, and sticking them and anything else next to the wound. And getting bloody honey onto everyone and everything nearby.
Save your honey for hypoglycemia patients, or your buttered rolls, unless you have no other choices.

Save also your butter, Crisco, and any other concoction of cat piss, dog shit, and sourdough batter you got from your mom/granny/crazy aunt/some witch in the woods. Dumber than hell, and probably not a good idea, plus someone else will have to traumatize the patient later by scraping all that happy horseshit off again, somewhere down the medical pipeline. Neither patient nor practitioner will thank you for your misguided efforts at that point.

If the Zompocalypse has already occurred, you're on your own; use your best judgment. Starting with some judgment, sil vous plait.

And once a wound scabs over and seals in a few days, topical goo is pointless.

Dress the wound(s).

Sterile dressings, completely covering the injury.
Non-stick, if appropriate.
Absorbent and multi-layered, if appropriate.
Occlusive to air, if appropriate.
This is where your variety of bandaids, 2x2s, 3x3s, 4x4s, ABDs, and multi-trauma dressings will kick in.

Bandage the wound(s).

A dressing protects the wound; a bandage secures the dressing(s). Dressings therefore, must be sterile, because they're going on open wounds. Bandages only have to be clean.
Sterile is nice, but you can, for example, wash bandages that have gotten soiled, bloody, or dirty, and reapply them once they're dry.
Dressings get burned or red-bagged afterwards; they're single-use.
Plain gauze, Kerlix fluff, Kling/Coban/vet wrap, ACE wrap. Or even cut-up sheets in rolls.

Nota bene that old-school field dressings and new Israeli bandages in all flavors are both dressings and bandages. Less flexibility, but less bulk, and handier if you aren't the medic, nor carrying the well-stocked aid bag.

Secure the bandage(s).

Tape gauze so it doesn't unroll. Tape metal Ace bandage clips so they don't pop out (or get the cool ones with Velcro tips). Make things fit, and stay put, despite the patient walking, being carried, put on a helicopter, or just sitting out on a windy spot.

Wounds get dressed and bandaged before splints go on broken limbs.

Dressings get changed daily, and whenever soiled. Note that "soiled" means "funky from the outside dirt, water, and other contaminants". The stuff draining from the wound inside is why you change them daily anyways - unless we're talking dressings that are saturated suppurating puss buckets. In which case you have bigger problems than dressing changes.

There are a host of special application dressings and bandaging, many of which protect skin by not having you rip and replace adhesives daily. These can be learned from the appropriate chapter of a decent comprehensive textbook of nursing care, for instance this one ($25-80 on Amazon):

You can also download the 1957 Army Field Manual on Bandaging and Splinting for free, here.

Smartest would be to acquire both.

One way or another, you will see this material again.

Monday Medical: Hypothermia

Never as funny IRL as this looks.

Hypothermia is technically anytime your body's core temperature is below 95° F.

Last week, Southern Califrutopia had its first "cool" day of the season. Cool is a relative term.

Hereabouts, it means shorts and a T-shirt aren't cutting it. We only visit snow in the mountains, we don't live in it, and our snow blower is called "the Sun". For some of you in other hardier places, our cool temp would be what you call "summer". YMMV. The greater lessons still apply.

Nonetheless, it wasn't that cold, even here. But my patient was over 60. Strike One. (Big risk factor. Older people, just like kids, don't cope well with thermoregulation, both having less muscle mass to generate heat, and a wonky temp control system. One because it's new, the other because it's worn out and old.)

And it was a perfect day for hypothermia. Low 50s. Overcast, hazy sunshine. Breezy, occasional drizzle. Strike Two.

Because on really cold-@$$ days, (and as I said, that is whatever it is to you, in your area) you bundle up. But 50s is just right for thinking, "Hey, it's just brisk, and I'll be working, not sitting, so I don't need to layer up."

My guy spent the day doing yard work. Six hours non-stop. In a sweatshirt.

Strike Three.

Kids, write this on your hand with a laundry pen: 

Cotton KILLS.

And I mean literally. It holds wet, and keeps it right next to the skin, on days when it's too cold to evaporate and dry off. Great in the desert in summer, but catastrophic for a wet day in fall or winter.

At 32° F., all that moisture next to your skin will freeze, wrapping you in a sheet of ice.

And. Then. You. Will. Die.

Deader-than-canned-tuna dead.

Frostbitten solid frozen toes and fingers and hands and feet and nose and ears dead. 

 Don't believe me. Wrap yourself in a bath sheet or beach towel, and soak it with cold water. Now go stand outside on a windy fall/winter day. 

(Please, come back in before you die, but after the point is driven well home.)

Silk, wool, and high-tech synthetics - like good old fleece - are all a hundred times better (or more) than a soaked cotton t-shirt and faux flannel shirt, plus soaking wet cotton jeans (that feel like frozen iron sheets), all made of 100% cotton.

No points for guessing of what 100% of my guy's sweatshirt was made.

Then, after he was worked out, sweaty, and already more chilled, he came in.

It felt hot inside (because he was part popsicled already). And because it was 20° warmer inside than out. But his internal thermostat was already out of whack. Strike Four.

So, in a genius move, he peeled off his sweatshirt (which had, indeed, become sweaty), and sat in front of a fan to cool off! Strike Five.

Which worked.

He rapidly cooled an already chilly body, after burning most of his calories, and was now sitting inside a cool room which took him to the near border of early hypothermia. Strike Six.

Oh, BTW, that 95° F. body core temp number?

Like scuba diving tables, that was determined by Uncle Sugar's best medical experts, based on the physiological responses of young, fit healthy studs in the Navy SEALs, Army Rangers, etc., with 5% body fat, and resting pulse rates in the 40s and 50s, not by testing the effects on out-of-shape 50+ sedentary adults. So for most people, you can throw that 95° number right out the window, unless you're in BUD/S now, waiting to start Hell Week.

This I where the family's common sense accidentally-on-purpose saved a life. Suddenly Paps was feeling weak, thinking fuzzy, not acting right, couldn't stand, and just didn't seem to be himself.

So they called 9-1-1. They knew something was wrong, just not what, exactly.

To arriving medics, given his age and chief complaints, he could have been a cardiac problem, like a heart attack, or a stroke. That's what they thought they had. Great guesses. But not really the problem.

When he got to me, he was shivering uncontrollably, on and off.

So badly that we couldn't get a temperature under the tongue.

Forehead and ear temps are really more like skin temps, not core temps, most of the time, and this was too big to risk on unreliable methods

Time for the tailpipe temperature: one red thermometer, inserted into the exit.

That's a core temp.

He had severe cardiac arrhythmia (really funky heartbeats), low blood pressure, lack of coordination, confusion, weakness, and moderate near-continuous shivering.

His magic number, on arrival at the E.D.: 96.5° F.

Technically, not the magic less-than-95°-F. number that equals hypothermia.

Reality: given his age, physical condition, and symptoms, he was already well into moderate hypothermia.

We put him in a Bair Hugger. It's like a giant hot blow dryer that attaches to a big air mattress quilt, on top of which you pile a layer or two of warm blankets. Think of it as human air fryer, and you're on the right track. After we peeled him out of everything wet , and left him with just a flimsy (but clean and dry) cotton hospital gown. Within two hours, we'd brought him up to more than 98° measured orally, because he was no longer shivering uncontrollably.

Weakness: gone.

Shivering: gone.

Cardiac arrhythmia: gone.

Confusion: gone.

Blood pressure: normal.

Problem solved.

Wherever you live, environmental concerns are a problem, and unless you're Down Under in Oz now, it's approaching winter, so cold is the default environment.

Zero degrees with a -40 wind chill is bad, but you can get into trouble being just a little wet, a little old, a little out of shape, and a little under-protected.

{BTW, other risk factors are diabetes, thyroid problems, alcohol consumption, other substance/drug use, some Rx medications, and severe trauma. Strike 7, 8, 9, 10, 11,12, if you're keeping score at home.} 

 

Hypothermia creeps up on people, and they don't notice.

Shivering is an early sign.

Later, you stop shivering, because the internal thermostat in your head is fried, and you're freezing.

You're confused, sounding slurred (as if you were drunk), you're tired, drowsy, can't remember things, and uncoordinated.

You think you're warm or hot, so you start taking warm clothes off.

Your pulse slows, you may pass out, and you feel very cold.

Think Mumbling, Fumbling, Bumbling, Stumbling, and Tumbling.

And if someone doesn't intervene, you'll die, feeling warm and fuzzy on the inside, and being a frozen meat popsicle in reality. Like Jack, in that pic up top.

The treatment is simple: REWARM, rapidly. Get them out of the weather, out of wet clothes, and warm them, inside and out. Hot food, hot drinks, and anything else that you can use, will keep from turning a mild problem (frequently mistaken for other things) into a life-threatening one.

Cody Lundin (the hippy dippy barefoot dude co-starring in Dual Survival all these years, entitled his first survival book 98.6 Degrees - The Art Of Keeping Your @$$ Alive. He's a subject matter expert; it really is that simple. And that hard.

Layer clothes.

 

Dress warm enough to stay warm and feel warm, but not enough to sweat.

COTTON KILLS. Ditch it. Silk, wool or high-speed synthetics are the way to go.

Wear a hat! 90% of body heat is lost through the skin, and most of that right out your bare head.

Conduction sucks. If you sit on the ground put something between you and cold ground, rocks, snow, etc. (Duh.)

Stay well-hydrated. With WATER, not booze. Caffeine is a diuretic (makes you pee) too, and will dehydrate you. Go for hot, sugary drinks. Without caffeine.

EAT, bubbe. Food makes calories, which you need to generate body heat and muscle movement. Young  healthy military troops in cold weather burn twice the calories you do sitting in a cubicle, and even at 5000/day, they - and you - will still lose weight over time working hard in the cold.

Hot food, high in carbs, protein, and even fat, is healthy in cold weather. Fat has twice the calories of carbs or protein, and you need fat to stay alive at cold temps. Butter, mayo, guac, nuts, nut butter, etc., are all your cold-weather friends.

Like batteries, the heart gets wonky when you're cold. It's fragile, and prone to weird rhythms. Which can turn into cardiac arrest. Handle cold people gently. If the pulse stops, CPR starts.

Warm the core first, then the limbs.

I you see something, do something. The longer you wait, the worse it gets, and the harder it is to fix.

Anything from to bodies in a sleeping bag to building a bonfire, to dunking them in a tub of really warm water or a jacuzzi, can work. Use what you've got, and right away.

Stay frosty, but don't freeze your @$$ off.

That concludes your hypothermia briefing. In six months or so, we'll talk about heat emergencies.

Monday Medical: Tourniquets

Suggested by article comments at AP

The title is not a typo. Come Mondays, I'll start doing regular weekly medical posts. I'm jumping the gun with this one. Maybe you'll get two this week. After the recent Blogcation, I owe you some back content.

I hope you never need the info, but these are strange days.

tourniquet: a device for stopping the flow of blood through a vein or artery, typically by compressing a limb with a cord or tight bandage.

Note the keyword "limb". Neck tourniquets are saved for use on murderers, terrorists, traitors, serial rapists, child molesters, politicians, telemarketers, people who drive 40 in the left lane, and any other of the most egregious criminals in society.

Historically, tourniquets were considered the Dark Arts in medicine, esp. field medicine, because you were "sacrificing a limb to save a life".

That's how they used to be, mainly because they were done with actual cord, wire, leather straps, and narrow bandages. And thusly set up, sacrificing a limb is exactly what they do.

Do NOT do that.

A) Because you're a dumb@$$ if you do.

B) Because we have far better materials, and much more knowledge, training, and recent experience, plus hugely better examples to work with nowadays.

Peer-reviewed medical journal articles, and better equipment, have documented conclusively that tourniquets applied in battlefield situations have been left in place for up to six hours, with no neurological or functional deficits noted afterwards. Six hours from application to removal in surgery is one helluva window for first aiders. 

So how can you take advantage of it?

CAT

The original, and gold standard. For sale by North American Rescue for $30@.

You can put it on one-handed, crank the windlass until the bleeding stops, velcro it down, and drive on. One and done. You have four limbs; you would be well-advised to have four tourniquets handy, somewhere nearby. (Not all on your weapon, belt, etc., but one on the weapon, one on the belt, and two more nearby in a kit/pack/car would be a great way to go. When you need one, you'll need it right effing now, not in 10 or 45 minutes.)

How easy is it to use? 

One-handed, total time (with slow instructions), 00:01:15 to apply, from on to done.

You should carry extras.

I probably have a dozen or two of these, including a couple of orange ones I use just for training.

Why so many?

Power tools: in the shop FAK.

Vehicle kits, each, and extras.

Chain saw: on the chaps belt.

Shooting range cart: a mittful of 'em.

Big Boy Military Rules: your tourniquet is for you, your buddy's tourniquet(s) are for him.

He doesn't have any? How much do you love him?? Srsly. Explain the facts of life to him, and wise him up.

You only have one? How much do you love yourself??

These have been around for years. They're already up to generation 7, or more (I forget). Older ones still work. Why are they generally single-use? Blood contamination/decon. Critical life support gear. You already wrote the time applied on the used one. 

But after TSHTF, when re-supply is a critical problem, you may be less finicky about throwing them away after a single use vs. attempting to decon and re-use them.

***Important safety tip: Beware of Chinesium fake versions!***

They're out there, and in abundance, especially from the idiots at Amazon and affiliates. Buy yours from a reputable brick-and-mortar or online dealer. (Hint: "Reputable" does not mean "cheapest". That's a fool's economy.) I have a 5.11 store nearby, and NAR has a solid gold rep online. So do some others. But a Tupperware bin from Bubba's Qwality Medikal Emporium And Knives at the gun show is caveat emptor, unless you know Bubba personally, including his home address, and trust him with your life. YMMV.

And if you ever get stuck with one you can't get a refund for, smash it and burn it, just like you should for unfixably bad weapon magazines. Like fake $20 bills, don't palm off your bad counterfeit on some other unlucky schmuck. Take one for the team, and fold, spindle, and mutilate those POS fakes, with extreme prejudice.

If you find someone selling them, tell them.

If the seller doesn't offer a refund, or fold up their tent, out them ruthlessly and often until they do one or the other.

SOFT-TW

Same idea (not better per se, just different, IMHO) than the CAT, with an aluminum (versus hard nylon) windlass. And again, about $30 from Tac-Med.

Application? Pretty much the same.

Unlike the CAT, it comes pre-threaded. It's beefier. It has a belt-and-suspenders method to secure it. And comes in a couple more colors than the CAT.

It's also heavier, and tiny bit bulkier.

You pays your nickel, and you makes your choices. There's nothing wrong with either one, and I'd be fine using either one. I don't care which one you like better. It's a chocolate/vanilla question.

X8T

Stick it in and give it a spin. Click and crank.

Just another way to skin the cat. About $38 at Rescue Essentials.

Others

The SAM XT and the TMT are just newer knock-off CATs for all intents and purposes. And, probably, less corporate support or research, but that's just a guess. They should work as well as the genuine articles.

The RATS tourniquet gains you speed and ease of use, but loses any mechanical advantage of a windlass. It's also a lot narrower than I'd be comfortable using on someone.

There are also straps, like the Touniq-Kwik/TK4, and the SWAT-T. 

The TK4 is really just a strap that you shove something in and twist, which is a flashback to 1940.

The SWAT-T is really more like a phlebotomy tourniquet on steroids, allowing you to make a pressure dressing, but probably a lot less occlusion of bleeding possible than a CAT or SOF-T-TW, and if you try, you're warned not to pull it that hard by manufacturer materials and videos. But it could replace or supplement ACE wraps, etc., in a kit where space is at a premium.

Getting into the Stupid Zone, there's the SAM Junctional Tourniquet. It's a bona fide medical device, complete with BP cuff inflation bulb, and works for pelvic fractures and other hard-to-tourniquet spots like armpits. But that complexity makes it iffy in hard use, and more failure prone. Plus, with a price tag of $350-$400+, each, (yes, you read that right) it's geared towards hospitals, public agencies with deep pockets, and solo users with generally more money than brains.

There are probably eleventy others if you dig deep enough, which I won't. These are the best quality of what there is, and most of what's out there, until someone else builds a better mousetrap. IOW, unless you've markedly improved on anything listed, IDGAD. As it is, I wouldn't use some of the above, but the information is there for those who march to a different drummer (or have their choices dictated by fiat from on high).

All of the above have How-To videos available on YouTube, etc.

TL;DRs

1)Get tourniquetSSS. 

Plural. From many, to a metric fuckton, depending on what you do or think (or fear?) you'll be doing.

2) Train On/Learn How To Use Them.

On every type you have. Including one-handed, for self-rescue.

Not just watching the videos.

3) Practice with them.

Frequently. Get a dedicated trainer model, and practice hands on. Nothing less will suffice for mastery, especially bearing in mind that you or someone else will be screaming, in excruciating pain, and gushing blood when you're doing it. This is NOT something you want to re-familiarize yourself with OJT on the day, under those conditions. Learn now, succeed later.

With ALL of your tribe. Family. Co-workers. Team. Neighborhood security group. Hunting buddies. Circle of fellow BSers. Everyone who knows how to use one is one more person who could save lives if things get sporty. Teach people in non-tactical circumstances: power tools, chainsaws, auto accident response, CERT/earthquake/disaster preparedness. You don't have to approach everything like Paul Blart - Mall Cop, Tacticool Timmy, or Gunkid with his Tactical Wheelbarrow(tm). Exsanguination happens all kinds of times and places.

4) Stock them EVERYWHERE.

For all of the above reasons. In job lots.

Imagine you were a bystander at the Route 91 Harvest Music Festival. Or a cab driver nearby afterwards. Not just the staff at Sunrise Med Center ER. You don't have to be able to save everyone. But what if you could save one person? What if it was a family member, or friend? What if they could save you, the next time?

Get busy.

Plan B (And C. And D. And E. &c.)

WRSA has a link to an American Partisan article by NC Scout, with a sobering thought:

"I’m sure you have thought about what happens when the hospital notifies the Anti-Terrorist Police about the GSW that just showed up at the ED entrance."

Firstly, NCScout's homemade blowout kit is solid stuff.

No quibbles.

As far as it goes.

But slapping on some QuickClot and an Israeli Battle dressing isn't the end of your GSW problems, should such befall you; it's only the beginning of them.

Ignoring the yuuuugely unopened can o' worms behind high-velocity penetrating trauma, and where bullets go, and what they do, and why the sea is boiling hot, and whether pigs have wings, we focus on a nominally so-called "uncomplicated" GSW.

I.e., the "flesh wound" of legend and lore.

IOW, even if no major bones, blood vessels, nerves, or other important bits and bobs are hit, a simple in-and-out, through-and-through projectile hole will still find eleventy ways to kill you deader than canned tuna, if all you've got in your magic bag is anticoagulant and a constrictive pressure dressing.

I've only been toiling in this particular vineyard for about a quarter century, so I may miss a thing or two, but let's take a slightly deeper peek at this from my side of the fence, so at least the brighter lights out there will have some wee appreciation for reality, and make a dent into knowing what they don't know.

Given: You have no major bleeding issues, and largely no problems with function, and you elect to skip the E.D. for reasons of your own. And you pounded in your hemostatic dressing, and wrapped it well with an IBD, ACE wrap, Coban, VetWrap, or strips of granny's torn-up knickers.

That's great.

For now.

What's next?

In no particular order:

1) When was your last tetanus (probably tDaP*) booster?

Why? Because you've got about a 72 hour window from puncture to an express ticket to the graveyard if you ain't got one of those. For cat bites and rusty nails, anything less than 10 years is probably ok. Bullet holes, 200 yards of donorcycle roadrash, or a shark or crocodile attack, and 5 years or less is much better. You probably got your first one between age 4 and 6. You got a booster between age 14 and 16. So if you're 26 or older, and don't know when your last booster was, you're already doing it wrong. They're cheap, easy, and can be had at drug store pharmacies and most any Urgent Care doc-in-the-box, for around $20-40, just for the asking. Make sure your tetanus booster status is up-to-date. Period. You WILL see this material again, IRL.

FTR, tetanus spores live on everything. Not just on rusty nails. Any hole in your people suit allows them to get from outside, in the air, to inside your meatsack, where they reproduce away from oxygen. And make a new home. That's not the problem. As a byproduct, they produce a toxin, which increases until it paralyzes all your muscles. S-L-O-W-L-Y.

And after about Day Three, the booster is too late to head the infection (and associated lethal paralysis) off at the pass. 

You. Will. Die.

Horribly.

For those of morbid curiosity, that would be with your body bent as all the muscles in your back contract, and draw you up like a bow, with only your heels and head touching the mattress, awake, unable to swallow, dying of thirst and starvation, fully conscious, until your diaphragm and rib cage muscles can no longer suck air, and you die staring at the wall behind your deathbed, in excruciating agony. Unless someone kindly holds a pillow over your mouth earlier until you stop breathing sooner, to cease your further descent through the levels of living hell before you embark upon the afterlife, or oblivion.

As iconic baseball manager Casey Stengel used to tell people, "You could look it up."

This description is from the era before there was a tetanus vaccine. About a century hence.

To the crybabies and pussies who whimper, bitch, and moan about a simple shot, I generally lay this out about this fast, and let them ponder

Tiny injection...horrible grisly death. Tiny injection...horrible grisly death.

Choose wisely.

But wait! There's more!

 2) What about what physicians referred to quaintly from 1500 A.D. until about 1930 as "mortification"?

IOW, you're going to get an infection.

Bullets aren't sterile.

Neither was your skin on the outside, before it became a new orifice.

Neither were the clothes you were wearing when a portion of them was injected into your body at upwards of 800fps, or worse.

QuickClot ain't fixing any of that. Every minute after the initial corporeal insult, a veritable Noah's Ark of bacteria are doing what they do: eating, dividing, and multiplying.

Inside of you.

They're going to make you the new lead solo in the Choir Invisible in about a week, left unchecked.

Septicemia, gangrene, and assorted related nasties will all have their way with you.

Unless you get some antibiotic prophylaxis. I.e. something to kill those cooties, and give your own immune system a leg up on winning that battle.

Currently, antibiotics in the cephalosporin family are the first-line choice for uncomplicated pentrating trauma.

A gram of Ancef given as a butt dart, followed by a week to 10 days of Keflex tablets will generally suffice. I leave it to the brighter and more motivated to research dosages and regimens from the standard medical trade references.

If you're not allergic to them.

If you have no contraindications for them.

If you have an IQ above that of plant life, and have researched what, how much, and how often to take them. And when not to. And what to watch for during and after. And when to know it ain't working.

If you can get your hands on them, both, and in sufficient quantity for a full course of treatment. Or the second- or third-line alternatives. (People who half-ass their antibiotic therapy, and quit early, aren't just quitters. They're generally referred to as morons with low gray matter titer, and future inhabitants of Boot Hill, in the trade. Don't be That Guy. For the younger set familiar with That 70s Show, the phrase you're thinking of is "Dumbass!").

Hint: There's a reason 18D school for SF medics is somewhere around 18 months long, and it's not for PT and obstacle courses. There's a lot of stuff to know, cold. Patients don't come with multiple choice bubbles tattooed on their chest.

Still not close to done, kids.

3) What about all that formerly viable flesh in the wound channel turned into non-viable chum?

It's maybe going to need removal, before it becomes food for #2, above.

Sooooooooo…..got local anesthesia handy?

How about general anesthesia; and someone to administer it, and monitor your vital signs until you wake up, and reverse any overdose, or 57 untoward effects, and the medicines to do all that?

Oh yeah, and someone to do the actual carving work while you're numbed up, or knocked out? (Look, Ronin was a great flick, as was John Wick: Parabellum, but absent a scriptwriter with a vivid imagination, and a paycheck like DeNiro or Keanu Reeves, you ain't gonna do the operation yourself, biting on a leather strap, and sewing yourself up afterwards while looking in a handy mirror.

Simply. Not. Happening.

So...d'ya know a good surgeon? Or even a bad one? Or a simple MD? A physician's assistant? A dentist? A vet? A former 18D with a sense of adventure? 

4) What about pain control, now, and later?

What, you actually thought this wasn't going to hurt like hell, or that you'd get by on a couple of motrin and maybe a slug of gin?

As if.

5)What about related problems? Side effects? Bad outcomes? Physical therapy? And tending to you, including changing dressings, wound care, and drug therapy, not to mention making sure you get rest, food, and drink, daily, including making sure everything works coming in and going out, and notices when it isn't, until you're completely back to normal, status quo ante? (Hint: In the trade, we refer to that last compendium as "nursing". I or any good nurse pulls six figures/yr for a reason, and it ain't for juggling bedpans, despite the lame attempts at wit by morons who don't know any better.)

Somewhere close to now, you should start to realize that while it's a good first step, merely slapping a battle dressing on a bullet hole isn't going to cut it, unless your clever plan is to simply die a week later, at home, sitting in a puddle of uncleaned feces and suppurating pus.

We repeat, NC Scout's list is a good beginning point. An IFAK and a hospital are both useful items, but they are hardly interchangeable.

Best do a long re-think for Spicy Times, and secondary and tertiary sorts of considerations.

As CA told you in the OP above,

"Plan accordingly."

Or else, keep your life insurance paid up.

I repeat:

You WILL see this material again IRL.

*(tDaP = Tetanus, diphtheria, and pertussis - AKA whooping cough. Because your childhood shots for those ran out of gas decades ago, and yet the ongoing influx of unvaxxed yard monkeys from all these Turd World countries like Shi*holia and Trashcanistan arrive here over the back fence instead of through the front gate - i.e. legally - and without benefit of things like a First World course of vaccinations against Life's Little Catastrophes. Like tetanus, diphtheria, and whooping cough. Not to mention plague, TB, Chagas Disease, and about 4M other exotic nasties formerly confined to...wait for it... Sh*tholia and Trashcanistan. QED. Now ask me again why your medical bill here is so much higher here than it is for folks in those tropical paradises.)