Wounded, Alone, but not Helpless
If the Boston Bombing woke us up to anything, it would be that danger could be lurking in any corner. While we can’t live our lives in fear, we can be prepared to meet it at the door and handle the after effects. Training is the key to preparedness.
Many of you reading this may have a military background, and one of the benefits of a military education is the amount of cross training every soldier, sailor or airman receives. Beyond first aid and CPR, most military members learn battlefield medicine—treating sucking chest wounds, truncated limbs, protruding bowels and so on. The primary reason for this is in battle conditions medical help may not be readily available; however, many injuries are survivable with a healthy dose of training and a modicum of preparation. This fact should not be lost when you consider the dangers everyday citizens face on a daily basis.
Ask a military medic about battlefield medicine and you’ll likely discuss the acronym M.A.R.C.H.—Massive hemorrhage, Airway, Respiration, Circulation, Hypothermia. This is a great plan for the deserts of Afghanistan or a hot zone in some foreign urban area, where EMS won’t be rolling to your location in a matter of a few minutes and you may be hours away from the nearest trauma center.
I recently learned of a better mnemonic—Call A CAB ’N Go Hot—from Dr. John Wipfler, a local emergency room physician who also supports three local SWAT teams as a tactical physician and medical director. Dr. Wipfler literally wrote the book on tactical medicine, along with three others authors—Tactical Medicine Essentials—and is currently teaching and developing courses for law enforcement and tactical medics.
I had an opportunity to interview Dr. Wipfler. He explained Call A CAB ’N Go Hot. His work is a fascinating read and must have for any survival or tactical medicine library. The tips are designed for individuals with some medical background, but broken down in such a way that the layperson can understand.
Call-A-CAB ’N Go Hot
- Call: Call out for help and communicate with your unit, or 911 in a civilian circumstance, and tell them what is happening. Use appropriate communication such as hand signals, your voice or a portable radio to let your fellow teammates, friendlies or family members know what is happening and where the suspect and threats are, with the goal of preventing the injury or death of others. Ensure your backup, loved ones, law enforcement and EMS know what the current circumstances are and where the threats are located; obtain help with neutralizing threats and medical care, extraction and evacuation. This may briefly need to occur simultaneously with the next step, A.
- A: Abolish threats: Identify and abolish all threats appropriately. After abolishing or minimizing the threats, the patient is extracted to nearby hard cover (cover that will not be penetrated by a bullet), where the tactical patient assessment process can begin with rapid stabilization. The same is true if you are alone and injured, but you may be moving to hard cover while dealing with the threat. From there, evacuation and transportation should occur, with advanced medical care provided along the way. Tactical medicine providers (TMPs) do not provide medical care until the patient reaches hard cover or hard cover is brought to the patient.
- CAB: Circulation, Compress bleeds, use Current (AED) if indicated for non-traumatic collapse, followed by Airway, then Breathing support. Then, if indicated, decompress a tension pneumothorax (a pneumothorax is an abnormal collection of air or gas in the pleural space that separates the lung from the chest wall and which may interfere with normal breathing) or place a one-way-valve dressing over a sucking chest wound.
- ’N: Neurologic status check: a rapid neurologic assessment to determine the patient’s mental status and identify any significant spinal cord injury.
- Go: Go to the appropriate advanced medical facility. The patient is extracted, evacuated and transported in an appropriate vehicle at an appropriate speed according to the seriousness of the patient’s condition.
- Hot: Hot is a reminder to prevent hypothermia and maintain body temperature in the normal range. Casualties with trauma are at higher risk for death if their body becomes colder—especially less than 95 degrees F. Use a shiny, silver Mylar “space” blanket or poncho/coat to maintain body heat.
CTD Dave recently had the opportunity to attend a tactical medicine class with Dr. Wipfler. The level of knowledge and real world scenarios was amazing. If you cannot find a tactical medicine class in your area, at least look into adding some literature to your collection with one, or more, of Dr. Wipfler’s books.
Live Through the Situation
The first action you need to take when you are injured is to maintain a “combat mindset” and live through the altercation. Most gunshot wounds are survivable.
Never give up.
While focusing on the source of the injury (your primary attacker, a hit-and-run vehicle and so on), you also need to be focused on if, and where, additional attackers may be or where the next vehicle is going to come from. This will require you to fight through the pain, nausea and panic, thinking clearly and defining where your hard cover will be. At this point, you have not begun addressing any medical issues. Call to get help rolling and inform your support of your situation and location.
When you pose the question to a combat medic, “What is the first step when you reach an injured person?”
The response will likely be, “Return fire!”
Abolish the threat: It’s easy to get distracted by a loved one lying injured next to you or when focused on getting back to your vehicle to access your first aid. Until you have dealt with the threat, this will all be for naught. Remember, “Good medicine can be bad tactics.” It will be important for you to maintain that same mindset.
Abolish the threat, and then render aid.
CAB—Up until the injury occurs, the victim, possibly you, was healthy, breathing and well oxygenated. In fact, the oxygen in your blood is sufficient to sustain life for the next few minutes following a traumatic injury. However, the number-one preventable cause of death on the battlefield is extremity bleeding. Unfortunately, there exist very few parallel studies regarding law enforcement or civilian engagements. The best we can do is extrapolate data from gun battles in the military.
Once you arrive at the point where you can assess the injury, you’ll keep your weapon handy, however, you still need to address any bleeding. OLEAS and Israeli compression bandages may be enough. If you are alone with a significant arm or leg injury, or find severe arterial bleeding in a partner’s or citizen’s extremity, you are going to have to apply a tourniquet—fast. With practice, you can do this in 15 seconds. Direct pressure on gunshot or stab wounds to the abdomen and chest (torso) won’t do much good. These types of injuries are likely going to be deep and require surgery as soon as possible.
A—Airway. This one is pretty self-explanatory. The number one preventable cause of airway obstruction of a victim lying on his back is his tongue. Place the victim (or yourself, if you are injured) lying on his side in the rescue position—one leg and arm straight in line with the body and the other out to the side for balance. For punctured lung injuries, keep the injured side down to prevent blood from filling the good lung and causing suffocation.
B—Breathing. Ensure that the casualty is breathing adequately. Remember that the number two preventable cause of death on the battlefield is Tension Pneumothorax (collapsed lung under high air pressure). If the victim (or you) can still talk, this is a good sign; just get the injured individual to a hospital or trauma center immediately. At the point where the victim (or you) cannot talk or becomes unresponsive, the gases that are building up high pressure in the chest need to be relieved by inserting a needle under the clavicle (collarbone), on the wounded side, to allow the gases to escape. These needles are currently being issued to all Army soldiers.
The difference between Army soldiers and you?
Soldiers do not have lawyers on the battlefield second-guessing their actions and they have fewer options of EMS response. Perhaps these kits will one day be standard issue with the appropriate training to law enforcement and civilians here at home, but they currently are not.
N—Neurological check. A first responder normally does this.
- Touch one of the victim’s legs and ask him to raise it, and then repeat for the other leg.
- Ask the victim to squeeze two of your fingers with each hand. Note any weakness.
- If you are alone, you can do a self-exam systems check, feeling for injury and ascertain whether you can move and feel all of your limbs and extremities.
- If the victim is paralyzed, think about the possibility of a spinal cord injury.
This assessment is going to indicate whether you drag or carry a victim or consider waiting for a backboard and stretcher.
GO—Torso wounds are one of the most immediate and serious types of injuries that often do not get the timely attention necessary. Whether a victim is shot in the belly just below the chest or even in the buttocks, major blood vessels could be injured in the pelvic region, causing death in 10 to 15 minutes.
If you are by yourself and injured, do not try to drive yourself to a hospital if you can avoid it. Of course, there are situations in which you may not be able to alert anyone to your situation and therefore must drive as a last resort. If you are driving yourself, be sure to maintain a safe speed in the event that you pass out on the way.
HOT—For prolonged transport or if EMS is not readily available, body temperature is going to be critical. If you are wounded and alone or lying in the field, in rain or in snow, crawl into the back of your car and lie down on your side or seek other shelter if possible. If you are smart and have an IFAK (individual first aid kit) in your car, use it and grab the space blanket.
Remember, the majority of body heat is lost through the head and neck. If you can’t get to shelter, pull a jacket or other insulating material over you if possible while waiting for help to arrive.
When you pose the question to a combat medic, “What is the first step when you reach an injured person?” The response will likely be, “Return fire!” Your head should be in the exact same place.
Every tactical-minded person should have the essential items handy at all times. Tactical vests are ideal for carrying the key first aid devices in the front of the vest. Otherwise, you should carry an IFAK in a readily available pocket. Have on hand:
- A tourniquet
- A compression bandage (OLAES, Israeli) and nitrile gloves
- A small CPR mask wouldn’t be a bad idea either
Additional items to carry:
- Decompression needle
- Any other items, depending upon training and protocols
A wide variety of compact first aid kits are available and your life is worth every bit of what you will spend on them.
In the seconds or minutes after a significant injury, you can save your life or the life of a loved one, minimizing the extent of damage. Invest in a few kits that can save your life and those of others and instead of letting a serious injury become fatal, be your own lifesaving hero.
Disclaimer: This article does not constitute medical advice or formal training and is for informational purposes only. You should discuss all lifesaving techniques with your own physician, taking into account your personal state of health, prior to implementation.