Tuesday, October 3, 2017

Bandaging: Gunshot Trauma and Your IFAK

Disclaimer: I really hate it when a subject is this spot-on.

Prior to this past Sunday night about 11PM, I would have happily postponed this sort of thing in favor of more likely problems. But some folks might live in Chicongo, or be at a country music festival in Las Vegas, or something equally unfortunate on the day, so...

There's nothing terribly complicated about the Army's IFAK, or the one you should have handy, and the contents are rather basic.

Peter at Bayou Renaissance Man linked earlier today to the Army's IFAK packing list (pdf), which reveals nothing requiring much more than common sense to use:

8465-01-531-3647 100 Round SAW/Utility 1 Pouch, MOLLE II
6515-01-521-7976 Tourniquet, Combat Application 1
6510-01-492-2275 Bandage Kit, Elastic 1
6510-01-460-0849 Bandage Kit, Elastic 1
6510-01-503-2117 Bandage GA4-1/2" 100’s 1
6510-00-926-8883 Adhesive Tape Surg 2" 6’s PG 1
6515-01-180-0467 Airway, Nasopharyngeal 1
6515-01-519-9161 Glove, Patient Exam 100’s 4
6545-01-586-7691 Contents Kit, IFAK Resupply Kit 1
6545-01-531-3147 Insert (folding panels with cord) 1
6510-01-562-3325 Dressing, Combat Gauze 1*

Let's break it down, then talk about using it.
First, for the non-military, those thirteen-digit numbers are NSNs (National Stock Numbers) for the items in question. If all you put in the address bar of Google, Bing, or whatever engine you're using, the first fifty hits will be the exact item you're looking for, in case you weren't sure.
Followed by the military nomenclature for the items.
Want it in civilianese? No problem.

Bag for the stuff
CAT-T tourniquet
ACE bandage or 4" Israeli Bandage
2" first aid tape
nasopharyngeal airway
Nitrile exam gloves (2 pair)
a card with the military item list, above
inner pouch to hold the stuff organized inside the big outer pouch
QuikClot Combat Gauze

And for the really thick or lazy, I linked every item possible to Amazon.

So, 2000 rounds have just been pumped into various folks around you, one of whom is yourself, or a loved one. Now what?

1) Try to get behind something bulletproof ASAP (unlike 15,000 people Sunday night, unfortunately), WITH your patient(s), any way possible.
Because if you get shot while tending to yourself or someone else, then what good are you?

2) Put on a pair of the gloves. Keeps your cooties off the patient, and their blood off you.

3) Find the most serious wound(s). (You might deduce that a set of EMT shears, not included on the IFAK list, would be handy for cutting clothes to expose the wounds, as we've noted in prior posts on this topic. That would be wise.) If the wounds in question are in arms or legs, and they're spurting bright red (arterial) blood up and clear of the wound, grab that CAT-T tourniquet, put it on, and tighten it and twist the windlass bar until the spurting stops.
How do you do that?

As I told you earlier, get an extra CAT-T, open it up, play with it, practice with it, and learn WTF you're doing now, while you're not spurting arterial blood.

Patients have four limbs. So do you. This would lead the brighter folks to note that there may be more than one seriously bleeding extremity, and therefore think that more than one such CAT-T might not be a bad idea. That would be correct.

4) Find the next most serious wound(s). These will generally be either the head, neck, or torso. You should have already dealt with serious extremity wounds, but non-spurting wounds not requiring a tourniquet would qualify.

5) In all of those cases, apply the combat gauze to the wound(s). Then wrap either ACE wrap or the Israeli bandage over that wound, until you have applied enough pressure and bandage material to the wound to cover it, and stop bleeding.
How do you do that?

Once again, get an extra, and practice using it before you need it.

6) If your victim has been wounded in the mouth/face, and may be having difficulty breathing or swallowing/aspirating blood, that's what that NP airway is for. It's also known as a "nose hose" or "nasal trumpet" both because that's what it look like, and it's also what it sounds like when an unconscious patient is breathing through it. To insert it, you need a surgical lubricant (think medical K-Y) to help you slide the tube into either nostril. (The one I linked to includes one packet (!), but you might want refills). Skipping the lubrication step will be like trying to stick sandpaper inside a sweater sleeve, with the rough side out: it ain't gonna go. So lube it, and insert it, gently rotating it until it's fully inserted.
How do you do that?
And yet again: Get an extra, see how it works. If you practice it, manikins are better than people, because manikins won't struggle and try to claw your eyes out. but if you find a willing volunteer, well...

7) If you place a tourniquet, mark a "T" on the patient's forehead, and the time it was placed, in military time (e.g. 2230 is 10:30PM). This is because tourniquets, per medical trauma studies, can remain in place for up to 6 hours with no or minimal damage to limbs, but that assumes someone later on knows when you put it on, and that you put it on, because they saw that "T". So a laundry pen or Sharpie pen in that IFAK? Yet another good idea not on the kit list.

8) There's one more good idea not on the list. Someone shot in the chest, between the top of their shoulders and the bottom of their ribs (where the diaphragm lives) may be leaking air or bloody bubbles out their new hole(s). So having a chest seal (there are several types) is a good idea to place over that hole to let air out, but not in. Because air where it's not supposed to be in the chest makes breathing not work, and allows one or both lungs to collapse. If this happens, after about 5 minutes, it's known by the medical term "dying". Also, bullets may go in on one side, and come out somewhere else. So you may have more than one chest hole letting air in with a gunshot. Or there might be multiple gunshot wounds. Thus you may deduce that more than one chest seal is also a good idea. Once again, you'd be very bright. If you have a chest wound, and you aren't sure about needing a chest seal, better safe than sorry. It won't hurt, and might save a life.
How do you do that?

9) The band-aids? Troops always break into their first aid kit for boo-boo band-aids. You can too. No video for this one. If you aren't sure how to use it, beat your head against the keyboard until you bleed, get a Band-Aid, go to the bathroom mirror, and practice putting one on correctly. (My lawyer says to tell you I was just kidding about beating your head bloody on the keyboard. My inner NCO voice thinks if you're that stupid that you'd do it, learning to put one on is good training. Now you're covered either way, and so am I.)

10) The tape can be used like tape is used, including to secure the NP airway in place, or reinforce the tourniquet or elastic bandages, and twenty other things, including something to stick to the forehead of a person with darker skin, and write that "T" and time on with the sharpie. The contents card is to see what you need to restock your kit when you use stuff, and make sure it's all there each time you check it (annually is a good idea).

You now have in one post the entire first aid course you need to do everything you're liable to be able to do between the time someone (including yourself) gets shot, and 911 arrives, and/or someone with more stuff and more training takes over.

ADDENDUM: Not covered in this, nor contained in the IFAK, is any mention of eye protection. That's because before the end of the first year in the Sandbox, every Swinging Richard in the .Mil was wearing either ballistic goggles, or shades, 24/7/365. Where spurting arterial bleeding is a factor, something as simple as an $9 pair of chemical splash goggles or clear eyewear is a great help to keep blood (and ricocheting bullet fragments, etc.) out of your eyes. You don't have to walk around looking like Tactical Timmy at all times, but splash goggles or safety glasses are mandatory PPE in both EMS and the ER, for a reason. I keep a set in my kit, and you should too. Didn't mention it, because it's not part of the IFAK load-out.
Wear your gloves, and protect your eyes. If you aren't doing it, you're doing it wrong. Period.

Here's hoping you die of old age, and never need to break it out and use it.


Anonymous said...

Thanks! Gotta learn this stuff, If only for that "once in a lifetime event."

Even more important is if the "festivities" kick off and these are daily events.


jim rock said...

Great write up. Thank you. I find my z-knife is handier than scissors.

Anonymous said...

Thanks for this article,while a lot of head scratching going on about what happened in Vegas and why(needs to be thought through/investigated)this is a timely and useful lesson that folks hopefully practice and never need,i.e. tis something you can do in crazy times that may save your or someone else's life.I would also mention that if you live near bigger hospitals some offer free training in bullet wound stabilization/use of tools to do job ect.Sad that we even need to think about this but better to think and practice and hopefully find never need then to not have option.

Anonymous said...

Now, let us get real. Who is really going to carry a 100 round pouch with them everywhere?

Maybe you should think about what will fit in a cargo pocket and not be in the way of most activities, and will not make you stick out like a sore thumb and draw unwanted attention from security.

My sugestion would be a cat, and issy dressing and qc gauze. That will take care of you, and that is all you are really responsible for.

Weetabix said...

Excellent write up.

The QuikClot link goes to the nitrile gloves. Did you mean this: https://www.amazon.com/dp/B00HJTH5L2/_encoding=UTF8?coliid=IMSYHKGT7I5G2&colid=MY2WEPUFRJWP

Aesop said...

Pack it inside whatever you like. All you've done is re-list the key components, and it fits in what it fits in.
My goal was to break down what's inside, explain it, and show how to use it.
I think I succeeded.

You want to re-invent the wheel, go ahead on. I'm a firm believer in making things work for you. Personally, I've got a solid utility pouch that looks like a cellphone/pocket camera carrier that holds it all. (And my cellphone, and a pocket cam.) And goes with me to places like Disneyland, including through the metal detectors there. (Yes, Disney security for guests is harsher than the airport kind, and has been for a couple of years.)

As far as who you're responsible for, if you have a wife and/or kids, your perspective might change a bit. Go down an article, read the Daily Mail article on the shooting I linked at the bottom, and dig down to the bottom half, where they started talking with people who were shot, or had family or friends shot.

The ICU/trauma nurse husband who shielded his surgeon wife's body, and died that way, was rather pointed, and moving, as were the other stories.

Real life is messier, and a bit different than "Fuck y'all, I got mine", in many cases.

Aesop said...

Thanks for the heads, Weet! I'll fix that immediately.

Anonymous said...

Have carried basically this kit minus the nasal tube for years. Since in commuter train and subways tunnels added a 60 minute smoke hood. Can't get people out if you are a smoke inhalation casualty. Was a firefighter for twenty years and one or two good lungfuls of the wrong kind of smoke and you are down.

Swrichmond said...

Add a couple of sealed 10cc syringes of normal saline for flushing things, like eyes. I also have hemostats and a shears, sterile sutures, packing strip, a sterile retractable scalpel. I need to double up on the tape that's in here and add some other stuff. I am not currently equipped to deal with a sucking chest wound and I need to fix that.

Aesop said...

Syringes are tough for some folks; try sterile saline eyewash:




They also get you some pressure to wash out debris from wounds.

Unknown said...

"2) Put on a pair of the gloves. Keeps your cooties off the patient, and their blood off you."

This one doesn't really apply with arterial bleeding, as time is of the essence, and blood is going to get on your forearms, upper arms, chest, neck, head, etc. That shit spurts EVERYWHERE. If you can put them on, great-you may not have time to do so, and likely won't keep the patient's blood off of you.

Aesop said...

Not true, and the video on chest wounds notes it as well.
The glove becomes the occlusive dressing.

If you didn't put the gloves on first, and fast, you're doing it wrong.

Your hand isn't going to get you anything that'd help.
And if you have an arterial bleeder, the TQ is the item that matters.
Not your hands.

It's also a lot harder to do because that much blood is slippery at first, then sticky afterwards. And, like at the concert, there aren't a lot of sinks to wash up in and continue on.

Gloving up takes two to three seconds. If time mattered that much, they're going to die before you turn around, and that's just a fact of trauma.
Nearly 90% of the GSW victims in this incident lived; about 10% were DRT: Dead Right There.
That's Rule Two in action.

Gloves go on first, period. Nobody ever heroically died from liver failure or AIDS after contracting a blood-borne pathogen months or years earlier. They died of terminal stupid.

But what do I know, I've only worked GSWs, both in the field and in trauma ERs for about 25 years.

And I didn't even mention eye protection, because in the .mil everyone was wearing ballistic goggles or shades by the end of Year One in the sandbox.

Anonymous said...

In a recent CLS (combat lifesaver course). We were told the sharpie should be gold or silver , to mark as many shades of skin as possible, and that the time should be written on the white retention Velcro strip on the CAT .

This is a *great* article; thank you very much.

Anonymous said...

extra gloves, read the palm and finger mils find ones that are not stupid thin and get the ones with the longer cuffs. as any ems person know, first time a glove breaks you will be pissed; it is one more thing to process and change in fast moving situation. you will need more gloves than you think. change between victims, use as chest seal, give to a by stander, etc. NPA airways I have found 28-32 seem to be good not to thick and can be cut with shears to reduce length. carry more than one. if you need one why not use two open a second airway. then think if you need to start breathing, you got pocket mask or barrier shield. then suction, that syringe with a nasal airway attached can be used as improvised suction and eye flush. if you have a suction tube and suction yankauer. that is the thing this is not your BLS/ALS kit it is a mini kit. you also need to review triage, 5 people doing cpr on a trauma induced cpr PT while a 2nd or 3rd or 59th victim bleeds out. you must be willing to walk away. I've done it and it is gut wrenching.

Aesop said...

Field Triage: you mean like I did here? :)

Liberty4Ever said...

All great advice, well received and much appreciated. Time to relearn this stuff. Like the Boy Scouts say: Be prepared.

I'd also add the advice that I've been giving for over a year. Stay out of crowds. I've practiced what I preached. That advice was added to my standard warning of the last ten years. Buy rice. Buy beans. Buy guns. Buy ammo. Don't get on the boxcar.

Anonymous said...

Could you kindly cover, or point me to a previously covered write up, on abdominal GSWs? I'd imagine packing one of those would be out, typically. Is the treatment dependent on what area of the abdomen (organ placement)? Or, is it pretty much just bandage and pressure?


Weetabix said...

The CAT tourniquet link is unavailable. The guy in the video stressed using the friction buckle. Most of the ones I can find do not seem to have the friction buckle. They're listed as GEN something or other.

The question: is the friction buckle still necessary, or have they improved the design such that it is no longer necessary? I figure doing it right is more important than doing it easy, but I don't know what's "right" now.

Aesop said...

So it is.
Check the new link, which looks current.

Amazon probably only has a dozen people who sell it, I managed to find the one dud.

Thanks for the proofreading, Weet. Howyadoing these days?

As for the friction buckle, there's more than one way to skin this cat, (not CAT), and most of the tourniquets work just fine.
But it's the CAT-T that's in the OP IFAK list.
Most of the high-speed, low-drag TQs will do the same job.
And they almost always have a YouTube How-To video.

Weetabix said...

Doing fine. Same as always - too many interests for the time I have and having a hard time picking one to follow. I'm a bit of a dabbler. Your medical stuff always makes me think I need to put some time into first aid training and knowledge.

So, I'm not so much proofreading as taking this seriously. A lot of your medical advice is quite advanced, and frankly, it's often over my head. But this one seems doable and unfortunately timely, so I finally decided to get going on it. Then I can work up to some of your other covered areas.

And I have a new grandson. Kind of excited about that.

You? You seem to stay perennially busy.

Aesop said...


Congrats on the grandson. Like sodas, the best use is to play with them, shake them up, then give them back to the owner, and stand well back.

Perenially busy doesn't seem to cover it here. Just finished a contract, about to start working in Hollyweird for a spell.

Give my regards to anyone over at the Other Place that doesn't have a stick up their butt. I'm spitballing, but I'm guesstimating I now have about 50 times the audience that whole board does, so we're all better off. I mainly miss the input there from subject-matter experts, but not the knee-jerk ad hominem from the permanently butthurt. When I want more "We're not happy until you're not happy", I'll just clock in at work.

A few familiar names (whom I won't point out for their own protection) happily pop up here all the time, and a few more lurk, but none that'll admit to it lest they burst into flames.

Glad I gave you something worthwhile to accomplish, and thanks again for the feedback.

Weetabix said...

Being socially oblivious, I rapidly lose track of the sides in slap fights, so I wouldn't know who to hit up.

I'm a bit concerned - I hadn't realized bursting into flames was a risk. Will you be posting instructions on self care for auto-ignition? ;-)

Anonymous said...

Hey Aesop, I'm looking for kid size TQ and only finding something meant for surgery.

Any thoughts or suggestions?


Aesop said...

One size fits all.

I'm not aware of any purpose-sized pediatric tourniquets (which doesn't mean they don't exist).

But they're kind of outside the target demographic market, i.e. 17-45 y.o. military members.

Most of what you'll find are tourniquets designed for blood drawing and IV starting, not hemorrhage control in trauma.
Google leads me to this one:

While it happens, pediatric trauma requiring one is slightly less rare than unicorns, but I could conceive of situations where you'd want one.
One in a million, thank heavens, but it could happen.

Anonymous said...

I will be volunteering at my kids' elementary school, so I'll be around there more than in the past. School shootings are very rare. The chances of being there when one happens are even rarer... but that kid in CT died from blood loss even though people were there to render aid immediately.

And we've had 2 lockdowns for active shooter incidents in the past two years, although thankfully they were district wide and not specific to my kids' school.

Thinking about the situation, I discovered that most trauma gear, esp. combat TQs are built for their most likely market-- soldiers. People who typically carry a lot more muscle than a 6 to 13 yo. There are companies that build emergency response trauma kits specifically sold to schools, but don't include a TQ.

I'd like to have something appropriate, and would have a word with the nurse about leaving a bag in the nurse's office if possible.

Since I've got a bag in the truck anyway.....


Anonymous said...

@aesop, you might find this worth bookmarking




Recce Rifleman said...

Excellent post. Having taken CLS multiple times, a valid alternative for marking the time for the TQ application is to use the patient's blood.

Anonymous said...

I can clear up the question regarding the friction buckle. The extra loop on the buckle was meant to be used when the tourniquet is applied to the upper leg. The rationale was that extra friction might be needed to adequately compress the thigh, due to the increased muscle mass typically found there. On the latest version of the CAT, referred to by the manufacturer as Generation 7, the additional friction buckle loop was deleted as unnecessary.

As an aside, the CAT has been widely counterfeited by the Chinese for the airsoft market. Some of the fakes are superficially quite similar to the genuine article. There are subtle differences that are only apparent upon close inspection. The primary indication of a fake is the extreme flexibility of the windlass. North American Rescue has a PDF tutorial on their website outlining the other differences. Bottom line, the fakes will fail when used as a lifesaving device. The CATs also have a Velcro tab for recording the time of application. Older models feature the tab in white, while the GEN 7 CATs have a gray tab. I have treated leg wounds that actually required the application of a second CAT adjacent to the first in order to fully control the bleeding. Just some food for thought.

Suz said...

Thank you for posting this. This is the third or forth time in the past 2 weeks I have read an article about setting up an IFAK, so I think someone is trying to tell me something.

Also about a month ago, a friend working on firewood with my husband got careless with a chainsaw and wound up with 16 stiches in his leg. End of the day, tired and not paying attention, cutting a few that had been cut a little long as I had bitched him out over the last load where there had been a lot that needed to be re-cut so they fit into the stove...and, of course, I was off at work, so no nurse handy.
Told my husband I wanted to put first aid kits on both the big tractor and on the UTV as when we are out back doing "stuff" we have one or the other or both with us.

I had bought the chainsaw chaps and helmet 6 years ago as I am attached to my legs/eyeballs/etc., and while the guys have used the helmet with facemask to keep the sawdust out of their beards, they all think the chaps were just sissy-fied.
That night, my husband ordered a pair of chaps and a helmet with face shield for himself.

Santa is bringing 2-3 IFAK's to our house for Christmas. Thank you for the links so I can have my husband view them.