Thursday, May 3, 2018

Wounds - Stop The Bleeding, Protect the Wound

Hours 5 and 6

Bonus Reviews:
Wound Care

(Hint: Big Green didn't tell you to put your gloves on so you don't get gooey or infected; nor do they worry about cleaning a wound before they dress it. I just did. Take the hints to heart, for your own sake, and that of your patient.)

There are a number of different wound types.
Those classically trained are taught APAIL:


The military, by contrast, describes wounds according to five different types:
Head wounds
Chest wounds
Abdominal wounds
Extremity wounds

At this time we'll cover the first four types.

Warrior Skills Level 1 :
Open head wound, pp. 3-68 through 3-71
Open Chest wound, pp. 3-59 through 3-62
Open Abdominal wound, pp. 3-56 through 3-58
Bleeding or severed extremity, pp. 3-62 through 3-68
First Aid, General principles - pp. 2-18 through 2-28
Specific injuries, pp. 3-1 through 3-11

Use the victim's first aid supplies first.
He didn't bring any? How well do you like him? Sucks to be him, right?
Expose the wounds.
If you didn't uncover and look at it, you're doing it wrong.
Find all the wounds.
One entry wound could make between zero and fifty exit holes.
No points will be awarded for doing a beautiful job on one wound on top while your patient bleeds out from the one you didn't find and treat.

Note also that the Warrior Skills cover current TCCC procedures where appropriate.
TQs and chest decompression were formerly regarded as doctor juju before the late sandbox unpleasantness, but now those skill sets have percolated down to every swinging Richard. We'll cover them again as part of TCCC, but for now, note the proper info in the checklists.

Head Wounds:
Chest Wound:

Abdominal wound:

Extremity Wound:

Other notable points:

Big Green uses standardized gear, because they can, and the supply tail is huge and endless.
Your choices, and your supply chain, will be different, and may be severely circumscribed.
Use what you've got, and do the best you can, with what you have, or what can use to improvise.

Get out the gear you have/carry.
Get extras to use for practice and training.
Do the practice and training, regularly, and in varying conditions (day/night, cold, hot, windy, rainy, etc.).
People unhelpfully won't always be injured on calm, clear sunny days, or inside well-lit air conditioned classrooms. You learn that way so you know the basic dance steps. But you may have to tango on a cold, rainy night in a ditch beside the road. Learn how to do it now, so you don't have to learn it the hard way then.

(What difference could it make?
Tell ya what, grab your kit, and let's go open it up beside the interstate highway with all those semi-trailers blowing by at 70MPH. Then we'll bring in a Blackhawk or a LifeFlight for a medevac. And we'll do it in the mud. Let me know how it works out for you.)

Use the pass/fail test standards in the Warrior Skills book as your guide.
You should be doing those steps in order, every time. Know the individual steps inside and out, and the order of the steps. (You can improvise on your own, after you learn it the right way first. And if you're smart, you'll do it the same way, so you don't forget anything.)

When you can do all of the above, and can do them all cold, without prompting, it'll be time to break for lunch.


Anonymous said...

Went back to your "Wound Care" post (which predates "meeting" you over at Kevin's site). GREAT STUFF.
You are doing great and wonderful things here, brother. Thank You
Boat Guy

streamfortyseven said...

Triage of casualties is going to be a big consideration - logistics will be a problem, to say the least. I think the best that can be done is to treat walking wounded, anything else is going to be close to impossible. Any wounds to the trunk - center-of-mass - will be essentially untreatable, it would be what was known in the old, bad days as a "mortal wound". Same case for most head wounds unless superficial. Wounds causing compound fractures to limbs would be difficult to treat - you'd have to figure out how to put the limb in traction, set the bones in near contact (reduce the fracture), then immobilize for six weeks. Think about that for a minute. Realistically, we're talking about flesh wounds to limbs here, and keeping them from getting infected. The only way to treat NBC casualties would be to prevent them, however Clorox or similar, followed by water lavage, can be used to decontaminate the usual set of acetylcholinesterase inhibitor nerve agents. Probably a realistic appraisal of logistics should be made, followed by a set of rules of thumb for triage of casualties. Not pleasant, but I think necessary.

Aesop said...

Uh, no.
And that material has been covered before.
But thanks for playing.

streamfortyseven said...

I'm not sure where I went from triage to "shooting the wounded." Here's what I meant: "But wait- you didn’t talk about abdominal injuries- gunshots, sucking chest wounds, etc? No, I didn’t. The reason why is that there’s not that much without extensive training you can do for this type of injury. You can pack it with gauze (or a tampon) to keep it from getting worse, but the best thing to do is close it with a safety pin. You should not consider a needle decompression for a sucking chest wound if you have little medical training either. Doing so incorrectly or overestimating your skill can cause many more problems than it solves, possibly killing your casualty. Understand? Extremity wounds are the ones you can treat the easiest and also kill the fastest if untreated. So focus on what you can do (unless you’re trained in advanced medicine by an accredited institution) and leave the rest to people who know what they’re doing. I also didn’t reference pushing fluids- that’s left to those with training for not only administering fluids but for monitoring the patient for shock possibly induced by those fluids."

First aid for sucking chest wounds - Save those little plastic beverage bags, get something the size of the hole to push into the hole once you've put the plastic bag on top, secure with tape. Repeat as needed.

SecessionIsTheAnswer said...

First many thanks for the training posts. It is all very helpful!

Now regarding medical / tc3 issues, I would appreciate your advice / solutions to the following US serf medical acquisition issues:

1 - your experience / recommendations on crico kit for performing a cricothroidotomy

2 - your recommendations on suture kit vs. med staple kit. My experience says staples are much easier to use, especially in the field, but would like your thoughts.

3 - my experience is that LR’s are more effective, but storage & acqusition is a big problem, especially without electricity. So I think saline is probably a better choice. Again your thoughts/recommendations.

4 - recommendations on IV chatheters & related equipment - gauges, tubing, etc. to stock in kit?

5 - antibiotics recommended to stock?

Finally the real issue for us serfs - how the f@ck do we acquire the items above? I am not messing with you? Any of the above are not available to serfs. I can drive down to Mexico and buy antibiotics, but all the other stuff, especially the IV stuff is not available to serfs.

Would love to buy this stuff legally online, but so far I haven’t found a source. Apparently war on drugs and serf’s can’t be trusted meh, make these items restricted.

If you have answers, please enlighten me?

Aesop said...


1) Refresh your browser, and note that the topic is "First Aid", under the rubric of "basic training". Not, e.g. "Surgical exploration and repair of open abdominal wounds". That clever distinction is the difference between the first year of surgical residency, and the first week or two at boot camp for new recruits in the military.

And yes, what you can do is minimal - and doing exactly that is the entire farking point of the exercise!

As to "close it with a safety pin", I'll leave it to you to present the medical references for that approach (or, you can just wing it and defend it all on your own, off the top of your head), then explain to the class how your un-anesthetized patient, who may have access to firearms and such, is going to respond to and/or tolerate that approach, and finally what possible benefit (beyond keeping their blood off the carpet) would accrue from such a Mengelian mode of treatment, given that you've already stated that any intervention in such cases is basically futile.
Wouldn't it be better, at that point, to save precious and scarce safety pins, and just leave them with a hearty "Sucks to be you, bro!"?

2) You're leaping miles beyond where I'm going. The point of the effort is to get people who are basically trained. Hand-waving "Don't, for God's sake, do that!" is neither prudent, appreciated, nor welcome.

3) When you write of any first aid besides minor injuries as essentially wasted effort on the non-salvageable, you ignore medical and military history, common sense, and legions of data to the contrary. The average basic EMT, today, is in possession of a greater understanding of actual medicine - not first aid, but medicine, practiced by doctors - than that possessed by the average physician from prior to the turn of the last century. That's how far things have progressed medically in 120 years. Which primitive art managed to keep one helluva lot of civilization alive up to that point. Depending on the situation, you may not have 21st century medicine, or all the details - maybe.
But even what you can do is miles ahead of, e.g. Civil War-era medical treatment, which while as much medieval as it was modern, still managed to salvage quite an agreeable number of victims from the bloodiest war in our nation's history.
Look at the state of medical care in the world's worst sh*tholes, and then work forward from that state. All of Western medical knowledge isn't going to drain away in some dystopian World War Z/Book Of Eli fapfest.

4) People with nothing more than GEDs, and a lone TCCC class by dint of training and education, have been saving lives for a decade and change just fine, thanks, using the exact needle chest decompression which you decry. There's been a couple of wars' worth of medical data collected. Perhaps you've heard of them.
The medical literature is replete with the information, which is part of what I aim to convey.
Now, if chest decompression needles scare you, or anyone else, by all means, they should consider themselves free to not attempt it nor learn the skill. But don't endeavor to hamstring others at the same time. And don't expect anyone to hook you up when you're the casualty I question, right?

Aesop said...

5) With about a quarter century of emergency room trauma nursing under my belt at this point, yes, I've got a pretty good grasp on the situation, the implications of what I'm covering, and the potential pitfalls. I didn't just trip over an old copy of a .mil first aid manual last week, and then decide to write it up on a blog on a lark, nor AFAIK have I advocated handing chest needles out to random people at stripmalls, and telling the recipients that they are now board-certified thoracic surgeons. If I'm mistaken on that point, kindly reference the section wherein I transgressed.

6) You learn how to take care of your people, for whatever size group that is or may be, to the highest standard of medical care possible. Because if you don't, you're a civilization fail, a leadership fail, and a group/tribe fail, (not to mention someone who's going to be leading an Army Of One, until you get hurt) which was why I directed you towards the "We'll Shoot The Wounded" post.
Having seen, heard, and read verbatim comments to that exact effect pretty much any time you get a large enough group to lower the collective IQ, I'm way past entertaining or humoring that sort of empty-headed sagacity, because it's essentially a suicide mission, for the reasons explained in that post.

To quote one notable general, "Don't get stuck on stupid."

Anybody who wants to cover that nonsense can get a Google Blogger account for free, with a few mouseclicks, and peddle that codswallop on their own time and site. It won't hurt my feelings one bit.

7) You realize you're freaking out about stuff so elementary and non-controversial the Army teaches to 17 year olds, in the first week or two of basic training, and has done for decades, right? (Or did you think the references and pdf links I've included were just made up out of thin air?) This is the functional equivalent of throwing a fit because a shooting class will make small round holes in the paper targets.

That's how you went from triage (a topic and concept for actual designated medical specialists, and not for every swinging Richard) to shooting the wounded.
My suggestion, if I haven't made things clear, would be that you wait around for the sections on Land Nav basics, learn how to shoot a back-azimuth, and then walk out of the weeds and swamp bog, back onto the path at that point where you departed from it.

If the minimal amount of first aid I've covered so far (we're only four hours into a notional 20-hour block of training) is kicking your ass or pushing all your buttons, perhaps this isn't the post, or even the blog, for you.
I don't know you, so I can't make that determination.

So, did you want to talk about the weather, or were you just making chit-chat?

Aesop said...

@Secession is the answer
1 - your experience / recommendations on crico kit for performing a cricothroidotomy
Chinook Medical:
Everything you need. 38 bucks. Note that you can legally acquire everything without getting the kit, but you'd have to source the actual cric airway itself. The kit gives you everything in one place.
Get two, crack one open, and learn what you're doing from people who know, with the actual gear you'll use. As always.

2 - your recommendations on suture kit vs. med staple kit. My experience says staples are much easier to use, especially in the field, but would like your thoughts.
Skip both, unless you're stocking a full clinic for licensed professionals. Learn to use tape, and bandaging techniques.
Nothing I wrote here has changed:

3 - my experience is that LR’s are more effective, but storage & acqusition is a big problem, especially without electricity. So I think saline is probably a better choice. Again your thoughts/recommendations.
Again, neither, unless you're stocking an apocalypse/insurgency hospital, and will have the medical practitioners to run it.
If the latter, get all of both you can, and bear in mind that stuff "expires".
Hence probably "neither" is the go-to answer for most people.

4 - recommendations on IV catheters & related equipment - gauges, tubing, etc. to stock in kit?
See answer to #3, above.

5 - antibiotics recommended to stock?
All of them you can get, as deep as you can stock them. And make damned sure you know the benefits, risks, side effects, adverse reactions, dosage and administration frequency for any given use, and your patient's allergies, and, oh yeah, have a complete store of pharmacological interventions for when you give someone an anaphylactic reaction to something they didn't know they were allergic to.

This isn't serfs vs. professionals, this is serious shit, and far beyond the level where hobbyists can handle what's required, not so much mentally, but more logistically.
You're also proposing to replace a doctor with from 8-15 years of job-specific training, and a pharmacist with an eight-year training pipeline, and probably a nurse with 4 years more, and substitute a bag of goodies and a book or two.
Not such a great plan. At this point in life, I could get my PharmD. in 4 more years, and then I'd only be 8-15 years short of the medical license part. See if you can guess why I wouldn't do this myself unless it was literally post-apocalyptic, or nearly as dire.
The last place you want to have an "Oh, shit!" moment is without medical backup, on a shoestring, after TSHTF. And none of what you're after lends itself to grabbing two of those, like you were just adding some kerlix rolls and 4x4s to your jump bag.

You want to do an actual clinic:

Go big, or go home.
Don't forget the people with 4,8,12 years of high-level first-world training to make that work.
Just like you can't get an F-15 or AH-64 at the surplus store and take it up yourself, either.
It's not the ton of aluminum and steel that's the problem. It's getting it all to work right, and then hold together once you get off the ground that takes the expertise.

SecessionIsTheAnswer said...

Appreciate the info and links. Also recognize this is serious stuff, which is why I am asking for your opinions/recommendations.

That said and your concerns duly noted, nothing in my request is stuff I haven't done and most certainly will do should anyone in my family need it when things get sporty and/or I think it's necessary to save their life.

I get that there's definitely training required, but none of the above requires "doctor level" expertise and these are skills that can be taught and learned if you have the desire & intelligence.

I acknowledge lawyers & liability issues exist. So obviously outside my family, the public will get what's in my vehicle IFAK and nothing more till EMS arrives.

Again, many thanks for the info.

Aesop said...

You're reading me 5x5.
Short of dire circumstances, color inside the lines.
When/if things drastically change to the point you're on your own, let your conscience be your guide.
And I'll be answering some of your questions more fully in upcoming posts.