Tactical Medicine

I think that everyone who thinks of survival has thought many times about what tactical items they may need to give aid to anyone who has been injured in a tramatic situation. It may be in a bug-out-situation, in a patrol, or in a secure retreat location during pandemic, or other hypovolemic situation. Most if any have given any sort of thought on how to perform basic life savinging medical procedures regarding exanguination. Sure a minor surgical kit might be beneficial or Lactated Ringers intravenous solutions would help out. However few individuals actually know how to use these items.

One of the best books for any form of survival medicine would be "Ditch Medicine", available from Paladin Press. Another one is "Emergency War Surgery Handbook". Don't be decieved thinking that these and many other sources of information are concerned with injuries that not only occur in combat situations, but any situation where bodily fluid loss of any kind becomes life threatening. Accidents and injuries happen all of the time.

As a medically and trauma trained individual,I have found that there are 3 basic steps involved in all types of tactical medicine, regardless of injury type, location, or severity. Those are 1. Stop the bleeding, 2. Start the breathing, 3. Check Circulation and 4. Treat for Shock, the silent killer. The first steps are self explanatory. There are many different ways to accomplish this, and be advised this is only one option. The reader should also be advised to become sufficiently TRAINED in these proceedures before attempting them.

If you find yourself in a tactical situation (patrol, under attack, E&E situation)and the injury damages an artery which is spurting blood, or another injury where an extremity is severely damaged and hemoraging one may use a tourniquet such as the Combat Application Tourniquet (CAT) placed approx 2-4 inches above the bleeding site. Every member should have one of these on their body at all times during a Bug Out/Patrol situation, and preferably in a unit standardized location. Doing this keeps the injured individual able to keep their finger on the trigger and remain in the fignt.

“The best preventive medicine is overwhelming firepower.” Contrary to popularly-held beliefs, (which I was originally taught) recent studies from Iraq have shown that tourniquets can be left on for days without irreparable tissue damage occurring below and on the application site. I don't believe that I would leave a tourniquet on for that long but a few hours to return to a safe location, or defeat a hostile threat, will obviously not hurt anything.

Once the firefight stops or the person is evacuated back to a secure location you can begin to treat the wounded area for any other injuries and infection. For example you could now clamp off blood vessels or place wet packed gauze into the site to reinforce any clotting that may or may not have occurred already. Never remove ANY blood stopper or other type bandage that has a clot attached to it, or you will start the bleeding all over again. It is better to leave the original bandage on, until difinitive medical care can be obtained. However, you may have to take the risk of further bleeding if the site has not been cleaned sufficiently, and infection is a real possibility AND Definative Medical Care is not available. If definitive medical attention cannot be obtained with in a few hours you may find yourself fighting tremendeous infection.

After you have dressed the wound you can SLOWLY release the pressure on the tourniquet constantly checking for any uncontrolled bleeding. There are toxic acids in the lower extremety of the location of the TQ, which MUST be released slowly back into the system, or the patient may revert into a septic shock type situation. If the bleeding persists, you then can keep adding your dressings as needed until the bleeding is fully controlled.

If you have been trained, You could also use some suture material to actually tie the vein itself off or clamp it with a hemostat, this will completely stop the bleeding and if done properly will allow for the tourniquet to be removed. This is a temporary solution though. If the artery is ligated, The ara of the ligation should be available for the surgeon to re-anastamose the artery at a later time so ligatures could be placed on both ends of the artery to make it easier for the surgeon to find. This would have no adverse affect on the affected limb as far as circulation is concerned, in the case of a venous ligature because there are usually a number of duplicate veins inside each limb. If this were an artery you could still tie it off, however you would have to be extremely careful that you are 100% certain there is a backup artery available to supply that limb or body part with fresh blood. A simple chart of blood vessels in the human body would be invaluable at this point. Also most times, if the artery is severed across the diameter it will slip up into the surrounding tissue causing difficulty finding it without further trauma. If it is damaged along the lateral length of the artery, it will stay in place. Be carful that you do as little damage to the end of the artery, as damage will have to be removed before reanastamosis is performed. Arteries will only spurt from the proximal end so usually only one clamp is needed to stop the spurting.

Another thing to remember in a survival situation is that no matter how much you clean everything ,with the limited number of supplies you will have on hand you will never be able to obtain 100% sterilization. Do not spend excess time trying to sterilize something when just 15 minutes or less will suffice. but the key here is to be able to get the patient difinative care as soon as possible, and keep the wound as clean as possible in the first place.

Another important item to note is how exactly does one start an intravenous (IV) line? We all realize that IV fluids, especially when someone has been bleeding or is still bleeding, are very important to combat shock. However most people have no idea how to actually start an IV. If you have been trained and practiced this proceedure it is very simple. It would be well to learn this art, before it is needed. One of the most important parts of starting an IV line actually occurs before you think about opening a needle/catheter packet. The size of the canula is very important. The rule of thumb is if there is large volume loss, you must use the largest canula that is available. Many time three or four sites are inserted at one time. The first and most important thing is to verify the expiration date of, and the contents of the bag you are going to use. If it is not crystal clear, don't chance using it, and the expiration date MUST be current.

Assemble everything prior to putting the needle in the arm/leg/forehead/wherever you can. Put the tube on the IV bag/bottle, “charge” the drip chamber by squeezing and releasing it, open the stop gate and drain all of the air out of the line, get tape items ready, place all of these items close to where you plan on inserting the IV line at. The place of administration must be chosen. If large amounts of fluids must be given, a site in the hand or foot is not sufficient. The area in the bend of the elbow is the smallest place available for large amounts of fluids, usually bilaterally. A trained RN or Medic can do cutdowns near the clavicals, but these are not available to the untrained person. Sterile proceedures should be done including sterile gloves and betadine/alcohol washing of the administration site. I prefer the Over-the-needle- catheter type of IV catheters because of the guage of the needle, and they will usually work in this areas. Many smaller people, or if you have to start an IV in the hand, will require a "butterfly" type needle because it is smaller, and will more readily fit into the vein lumen. Using this style of catheter all one must do is insert the needle and catheter combo into the vein by inserting the needle to one side of the vein while using the other hands index finger to stabilize the vein, and keep it from rolling. (THE NEEDLE/CATHETER MUST ALWAYS BE POINTING TOWARD THE HEART IN A VEIN. YOU CANNOT PLACE AN IV INTO AN ARTERY WITHOUT A PRESSURE BAG, AND THEN IT IS USUALLY DONE TO ADMINISTER WHOLE BLOOD PRODUCTS). Then slowly and carefully advance the needle into the side of the vein. When this is accomplished, one will feel a distinct "pop". Advance the catheter into the vein, making sure that it is not lodged against a valve. When the blood appears in the flash chamber the start has usually been acomplished. Then one simply uses one'w index finger to “push” the catheter off the needle and into the vein. You may have to manipulate the catheter insde the vein to give the greatest flow because of the position of the valves. Never, never move the needle in a rotation under the skin, and if you miss the start, you must begin the process all over again with a NEW needle/catheter. Make sure to hold the needle barrel with at least your thumb and middle finger and push only with your pointer finger on the catheter tab. Once this is done and the catheter can move no further into the vein, i.e. it is all the way against the skin. Now is the other tricky part, with your right hand place the IV tubing under your arm and route it so the end just barely dangles in your palm with the tube wrapped above your thumb, take your left hand and apply firm pressure on the vein immediately above the catheter’s termination point. Slowly grasp the needle barrel with your right thumb and forefinger, at the same time grasp the colored plastic part of the catheter with the thumb and forefinger of your left hand while still holding pressure on the vein. Slowly twist the needle barrel to the right until it spins freely, now you can replace the barrel with the tubing connector of the IV line. Start the fluids flowing and you are completely done, except for taping up the site. At least one loop of tape should be wrapped around the catheter connection point and taped to the skin so as to "hold" the catheter "in", and an opsite adhesive bandage should complete cover and seal the site of the IV. If done properly the patient will not lose a single drop of their diminishing blood supply. In patients who are hypovolemic it would be the practice of running the first liter (bag) of Lactated Ringers, Normal Saline or other volume increacing IV solution full steam, wide open also known as bolus. This will rapidly expand the volume inside the blood vessels and allow the system a better chance of returning to normal. Do not however run more than 2 liters bolus unless advised by difinative competent medical control. I typically will estimate blood loss and run that much bolus and then run the rest of the fluid in that bag at [a slower] keep vein open (TKO) rate, which is usually one drop every second or so. I do this as slowly as I can while still keeping the vein open, if vitals start taking a dive I can readily switch back to bolus and give more fluids.

The only thing left to convey is to read and practice (pigs, both live and dead make good substitutes for humans in the present times) and become knowledgeable and comfortable with your medical skills should the need ever arise where you are forced to use them.

PLEASE NOTE:

I am not a licensed medical instructor/nor practicianer, and as such am not advocating or instructing ANYONE in medical proceedures. It is solely an informational article to be used for entertainment purposes.

You should never admisister or start IV's unless you are trained by licensed, competant medical staff, and unless you have standing orders from a medical director and have been trained and certified by your own State or Local Government. These directions in no way what-so-ever suggest that an untrained or unauthorized person can EVER start an IV or administer IV therapy without directions of a Licenced Professional.