tactical casualty care - crisis medicine … · class workbook this is your printable pdf ﬁlled...

TacticalCasualtyCare

©2017CrisisMedicineLLC

Navigation“I’mgoingtotellyouinthiscoursehowI’mgoingtosolveaproblem.”-MikeShertz

2• TACTICAL CASUALTY CARE

HOW TO BEST USE THIS CLASS

Beforeyoujumpin,wehaveafewsuggestionsonhowtogetstarted.

Togetthemostoutofthisclassyouonlyneedyourcomputerandadesiretolearn.Accesstorecommendedequipmenttopracticeisaplus.

You’llfindvarioushyperlinkstowebsitesthatmaybeofinteresttoyouthroughoutthisbook. Alllinkscheckedforaccuracy27November2017.

TheCrisisMedicineTacticalCasualtyCarecoursesaretheculminationof30yearsoftraining,experience,andresearchbyDr.Shertzresultinginanentertaining,science-based,cohesivecurriculumgaugedtotheskilllevelofeachgroupofstudents.Thispopulartrainingincludesthemedicalanalysistoteachstudentsthewhat,when,why,how,andhowbesttoaddresslife-threateninginjuriesinahigh-riskenvironment.

Drawingoncurrentandhistoricaleventsfromthemilitary,lawenforcement,andactiveviolentincidents(previouslyreferredtoasactiveshooterevents),Dr.Shertzusesphotographs,demonstrativemodels,andhands-onexamplesapplyingthetechniquestoprovidestudentsthetoolstheyneedtosavelivesandpreventunnecessarydeaths.

Attheendofthelectureandskillsstationdemonstrations,you’llalsoseethetechniquesappliedintheatricallyenactedscenarios.Thescenariosputallyourskillstogether,combiningintoasuccessfulcasualtyevaluationandtreatment.

CLASS WORKBOOK

ThisisyourprintablePDFfilledwithlessonsrecaps,specificinstructions,andsuggestedequipment.

SUGGESTED VIEWING SCHEDULE

Thisclasswhenpresentedasanin-persontrainingrunsalongandtiring10-hourdayincludingskillsstationsandascenariopracticalattheend.Werecommendwatchingtheonlineclassoverafewsittings,returningtospecificportionsonceyouhaveequipmenttopracticewith.

EQUIPMENT*

Dr.Shertzlaysouthisessentialequipmentastheclassprogresses,butinanidealworld,studentscanfollowalongathomeiftheyhaveaccessto:• aprovencommerciallyavailabletourniquet,CATrecommended• cravats(forimprovisedtourniqueting)• emergencytraumadressing• Kerlixgauze

You’llbewalkedthroughskillsstationdemonstrations,whereyoucanpracticeskillsasthey'retaught.

*Recommended sources can be found at the end of this workbook.


IntrotoCrisisMedicine“Iwanttogiveyouaplantomanage

preventabledeath…”

• Dr.MikeShertzbeganhismedicalcareerintheUnitedStatesArmyasaSpecialForcesMedic(18D)

• HeattendedmedicalschoolinNewYork,rotatingthroughsomeofthemostcrimeanddrug-riddenneighborhoodsinNYC.

• Aftermedicalschool,Dr.ShertztrainedatOregonHealthSciencesUniversitywherehewasselectedtobetheChiefResidentoftheEmergencyMedicineDepartmenthisfinalyear

• Dr.Shertzcurrentlyworksasaboard-certifiedEmergencyMedicinephysicianatoneofthebusiestEmergencyDepartmentsinOregon.

• Dr.Shertzhasdeployedandtaughtinfar-flunglocationsincludingKorea,Afghanistan,Iraq,andEastAfrica.

• TheWashingtonCountySheriff’sOfficeTacticalNegotiationsTeam(SWAT)runsatacticalmedicalprogramheadedbyDr.Shertz.Inthatrole,hetrainsandleadsacadreoffourembeddedmedics.

• Dr.Shertzisalsothemedicaldirectorforseverallocalfireagenciesandcompanies,includingtheHillsboroFireDepartment,andIntel’sOregon-basedEmergencyMedicalResponder(EMR)program.

• Dr.Shertzregularlytrainslawenforcement,fire,andEMSincludingparamedics,andlocalcitizensintacticalcasualtycareandtacticalfirstaidtechniques.

IntroductiontoTC2


MISSION STATEMENT:

Identifyimmediatelylifethreateninginjuriesthatcanbequicklymanagedwithminimalequipmentduringorimmediatelyafterahighriskevent.

How do we do that? What are the priorities?

1)Don’tgetinjured2)Protectthecasualtyfromfurtherinjury3)MARCH4)Getmorehelp

Debunking the ABC model in tactical environments

ThetraditionalABCmodelassumestheinjuryprofilecomesfromautoaccidents.Inthiscase,itmakessensetoaddressairwayandrespirationfirst.Inconsideringpenetratingtrauma,acasualtycanbleedtodeathinunder5minutes.Weneedtoaddressmassivehemorrhagefirst.

What’s a better model? M-A-R-C-H

Ourprioritiesaretodealwithmassivehemorrhagewhich,leftuntreated,cankillacasualtybeforeEMSarrives;thenwecheckforanopenairway,properrespirations,circulation,andlastly,hypothermiapreventionmeasures.

Phases of Care

1. CareUnderFire/DirectThreat:Whatmedicalcarewouldyouprovideinaburningbuilding?

2. TacticalFieldCare/IndirectThreat:Whatmedicalcarewouldyouprovideacrossthestreetfromtheburningbuilding?

3. CasualtyEvacuationCare:Thethreatislargelyover,thecasualtyisreadytobetakentothehospital.

Why does it matter?

40%ofVietnamcombatcasualtydeathsoccurredwithintwominutesofbeingwounded,20%weredeadbyfiveminutes,andanother15%weredeadwithinthefirst10minutesofwounding.

NOTES:

WoundBallistics“BarringCNShitsthereisnophysiologicalreasonforanindividualtobeincapacitated

byevenafatalwound,untilbloodlossissufficienttodropbloodpressure&/orthebrain

isdeprivedofoxygen.”FBIWorkshop,1987


NOTES:Therearealotofurbanlegendsaroundgunshotwoundsandwewanttodemystifythem-

➡ foreveryonefatalfirearmsinjury,➡ therearetwononfatalinjuriesrequiringhospitalization,➡ andfivenonfatalinjuriesnotrequiringhospitalization

Entranceandexitwoundsaregenerallyimpossiblefortheaveragepersontoidentify,anddon’tmatterintheirtreatment.

Col.LouisLaGarde,themanwholiterallywrotethebookonGunshotInjuriesin1916said,“Wearenotacquaintedwithanybulletfiredfromahandweaponthatwillstopadeterminedenemywhentheprojectiletraversessoftpartsalone.Therequirementsofsuchabulletwouldneedtohaveasectionalarealikethatofa3-inchsolidshot.”Nothinghaschanged.

Inconsideringwoundballistics,therearetwotheoriesofwoundingorstoppingpower:Psychologicalincapacitationandphysiologicalincapacitation.

Psychological incapacitationisnotpredictable-itiscompletelyunrelatedtothepotentialforanygivenbullettocausedamage.Thatis,ifthewoundedpersonismotivatedenoughtofight,theywillcontinuetodoso.

Ontheotherhand,physiological incapacitationiswelldocumentedandinvolvesthemechanicaleffectsoftheprojectilecausingdamagetothebody.Theonlyreliablewaytoincapacitateanindividualistointerferewiththebrain’sabilitytocommandthebody.Therearetwowaystodothis:one,directdestructionofthebrain/brainstem,orhypovolemicshock=bloodloss.

Which load to carry?

TheFBIconductsresearchtoevaluateloads.Theirconclusionswerebasedonthefollowingdata:Theaverageperson(atthetimeoftheworkshop)was9inchesthickatthechestfromfronttoback;acartridgemayberequiredtopenetratethroughinterveningbarriersbeforereachingthetarget.Thereforeitmustpenetrate12-18”intissuetoensureithasthepotentialtotraversevitalorgans.

*hollowpointbulletsinFBIgelatin

HemorrhageControl“Nooneshouldbleedtodeathfromextremityhemorrhage.”


Massive Hemorrhage is:

• Steadyorsquirtingbleedingfromawound• Bloodpoolingontheground• Bloodsoakedclothing• Bandagessoakedthroughwithblood• Thecasualtyhasstoppedbleedingandnowisnowinshock

Casualties can bleed to death from massive hemorrhage in just a few minutes.

It’snotjusthowmuchbloodyoulose,it’salsohowfastyouloseit.

RedCrossblooddonationsare500mLoronepint.Howbadlydoyoufeelafterwards?Onceyou’velost2000mL,youareinshock.

Extremity Wounds

InWWII,Korea,andVietnam53-55%ofwoundswereonarmsandlegs.10%ofallVietnamcombatdeathswerefromuncontrolledhemorrhageofanextremitywound.

HEMORRHAGE CONTROL OPTIONS

DIRECT PRESSURE

Directpressurecancontrolmassivehemorrhageifyoucaninterlockyourfingersandputaclamshellaroundthebleedinglimb,squeezingashardasonecan.Youcancompletelyoccludearterialflowusingthistechniqueandstopbleeding.Thistechniqueisobviouslymoresuccessfulonsmallerlimbs.

BANDAGING

BandagingusingKerlix,Israeli/ETDdressings,andotherpressuredressingscanbeusedtomanagenon-massivebleedingoncethetacticalsituationisresolved.

TOURNIQUETS

Commerciallyavailabletourniquetsarequicktoapplyandahandsfreemethodtostopmassivehemorrhage.Therehavebeenover10,000successfulapplicationsoftourniquetsintheGlobalWaronTerror(GWOT).Theolddogmafromthe1940’sabouttourniquetscausingamputationshasbeenaddressedanddebunked.Tourniquets,whenappliedcorrectly,aresafeandsavelives.

WOUND PACKING

Tourniquetsonlyworkonextremitywounds.Bleedingtotheneck,armpit,orgroincannotbecontrolledwithatourniquet,andwillrequirepackinggauzedeeplyintothewoundatthepointofbleeding.

NOTES:

HemorrhageControl“Wehavealreadylearnedtheselessonsinsomeone’sblood:Letsnotrelearnthem.”


NOTES: Provencommerciallyavailabletourniquetsshouldbeboughtdirectlyfromtheirmanufacturerstoavoidproblemswithcounterfeits,evenifitcostsmore.Atleast6companiesaremakingcounterfeitCATtourniquets,includingonepurportingtobeNorthAmericanRescueonAmazon(andisn’t).

TOURNIQUET APPLICATION

Toapplyacommerciallyavailable,off-the-shelftourniquetinatacticalsituation,putit• highandtightfordirectthreat/careunderfire-OR-2-3”abovethe

woundforindirectthreat/tacticalfieldcare• Securethedevicearoundthelimb(permanufacturer’sinstructions)• Takealltheslackoutoftheband• Twistthewindlassuntilallbleedingisstopped.Wegoashighaspossibleforareason:becausewedon’tknowwhereallthoseholesare,andwhilethethreatisongoingisnotthetimetolookforholesandinjuries.

“A properly applied tourniquet is going to be

pretty damned tight.”

IMPROVISED TOURNIQUETS

Ifacommerciallyavailabletourniquetisnotavailableandthetacticalsituationpermits,animprovisedtourniquetcanbecreatedfroma2-4inchwidestripoffabric,wrappedaroundthelimbabovethewound,securedwithasquareknot,andmostimportantly,tightenedwithawindlassmadefromasolidobjectlikeametalpen.JumpaheadtoseeDr.Shertz’smethodforusingthecasualty’sownclothingasatourniquet.

TAKE HOME MESSAGE

MoralNumber1:Nooneshouldbleedtodeathfromanextremitywound.

MoralNumber2:Directpressurewillstopalmostallmassivebleedingbutitrequirestwohands.

MoralNumber3:Whengooddirectpressureisn’tworking,orthetacticalstationrequiresyourhands,youneedatourniquet

(M)ARCHPneumonic“Startingwiththe“ABC’s”isafailureofrootcauseanalysis:Youwantanopenairwaytooxygenateblood,whichisbestdonewhileitisstillinsidethebody.”


HavingaddressedtheissueofM-massivehemorrhage,you’llwanttoturnyourattentiontotheremainderoftheMARCHpneumonic:

A-Airway

Isthecasualtyabletoansweryourquestions?Isthecasualtygurgling?Ishisvoicemuffled?Ishesnoring?Allaresignsofpartialairwayobstruction.Istheresomethingoccludingtheairway?Opentheairwaywithhead-tilt,chin-lift.

CareunderfireisnotthetimeforCPRandrescuebreathing.Ifhecan'tbreatheonhisown,he'slikelydead.CPRisusedtocirculateblood:Ifthecasualtyhasbledout,CPRwillnotaccomplishthedesiredtaskofcirculatingbloodbecausethereisn’tany.

Youcanputthecasualtyinapositiontoensuretheirairwayisopen.Learnabouttherecoverypositionin§3.3.

R-Respiration

Isthecasualtystrugglingtobreathe?Aretheyspeakingin2-3wordsentences?Takenoteoftheircurrentstatussoyoucaneasilymonitorchanges.Suckingchestwoundsgenerallysuckandblow,whichisthesoundofnotdyingoftensionpneumothorax.Doallchestwoundsneedtobesealed?Probablynot.

C-CirculationDoesthecasualtyhavearadialpulseandcantheyfollowinstructions?Ifso,theyhavea0.1%chanceofdying.Iftheyhaveneither,theirlikelihoodofdyingis41%.

H-Hypothermia Prevention

Coldblooddoesnotclot.Forevery1ºCelsiusdropintemperature,thedeathrategoesupby10%.Isthereablanket?Ajacket?Canyougetthecasualtyoutofwetclothing?Canyougetthecasualtyoffofthegroundandputsomethingunderthem?Doyouhaveahypothermiapreventionkit,blizzardbag,oremergencyblanket?

Skills: Head Tilt, Chin Lift

Thisisstandard,RedCrossprocedure:Placeonehandonthecasualty’sforehead,theotherhandcuppingthechin.Gentlytilttheheadbackpressingawayanddownontheforeheadanduponthechin.Thisshouldmovethetongueawayfromthebackofthethroatandallowbetterbreathing.

NOTES:

CasualtyPositioning&Movement“Casualtymovementisdangerousbusiness…Gettingwoundedrecoveringcasualtiesisnotcombateffective.”


NOTES: Movethecasualtyifthereisanimmediatedangeroryoucan'trenderaidintheirlocation.Don’tworkthemwheretheywereinjured;it’sdangerousthere.Thefirstruleofcasualtycareis:Don’tgethurt.

• Canthecasualtycometoyou?

• Drags-canyoudragthecasualtybyanarm?Byhistacticalgearorshirt?

TCCCguidelines:“thereisnorequirementtoimmobilizethespinepriortomovingacasualtyoutofafirefightifhehassustainedonlypenetratingtrauma.”

Blunt Trauma

Thereisadifferencebetweenpenetratingtraumaandblunttrauma,suchasthatfromacaraccidentorvehicleattack.Inpenetratingtrauma,eitherthespineishit,oritisn't.Inblunttrauma,thelikelihoodofotherinjuriestothetorso,head,andspinearemuchmorelikely.See,CrisisMedicineblogforafurtherdiscussion.

BLOOD SWEEP

Oncethetacticalsituationisresolved,andcareprovidersareinanin-directthreatenvironment,abloodsweepcanbeconductedtodeterminewhetherthereareadditionalinjuriesthatcanorshouldbeattendedto.Inanyactiveviolentincident,activatetheEMSsystemassoonaspossible.Havingmoregoodpeoplewithgunsandmedicalsuppliesalwaysmakesbadsituationsbetter.

RECOVERY POSITION

Onceyougetthecasualtywhereyouwantthem,putthemintherecoveryposition.Ithelpsthecasualty:

• Breathe,keepshisairwayopen,allowsfordrainageofblood&/orvomit

• Allowsrescuertoexaminethecasualty

• Keepsthecasualtysafeandcomfortable

BlastInjuries“Whichcauseofinjurydoesthecasualtyhave?Itdoesn’tmatter.Medicaltreatment

remainsthesame.Getthecasualtytoasaferplace,spinyourM-A-R-C-Hpneumonic,

andactivateEMS.”

G 0• TACTICAL CASUALTY CARE1

Civilianbombingsare3timesmoredestructivethaninmilitarysettings.Thisisthoughttobeduetodecreasedsituationalawareness,lackofprotectivegearorvehicles,andlackofperimeters.

Thereare4majoreffectsblastswillhaveonyourcasualties,whichaffectyourabilitytotreatthem:

Primary Blast Injuries -fromthepressurewave:Causeseardrum

rupture,ringingintheears,andtheremaybearelatedlunginjuryin50%ofthesecasualties

Secondary Blast Injuries -fromfragments:Thereisahigh

likelihoodofbleedingandthereforesurgery.Ensurethereisnomassivehemorrhagefromanextremity,orjunctionalhemorrhage,thengetthecasualtytothehospitalNOW.

Tertiary Blast Injuries -blunttrauma:theseareinjuriescausedby

thecasualtybeingthrownbytheexplosionandimpactingsomethingelse,likeawall,vehicle,etc.

Miscellaneous Blast Injuries:Includingburnsandcrushinjuries.

Althoughburnsarepainful,thereisnospecialcarerequiredforthefirst1-2hours.Airwayocclusionfromfacialburnscanoccur,soensureairwayisopen.Hypothermiacanoccurwithlargeburns:Preventhypothermiaeveninburnedcasualties.

NOTES:

*represents155mmtankshell

PuttingItAllTogether

0 1• TACTICAL CASUALTY CARE1

NOTES: CARE UNDER FIRE / DIRECT THREAT

Youandthecasualtyareunderadirectthreattolife:i.e.,burningbuilding,beingshotat.Goal?Makeitasbriefaspossible.Eliminatethethreat,seekcover,takethecasualtywithyou.Maybetourniquethigh&tightoverclothing.

Careunderfireisnotthetimetobefocusingonmedicalproceduresifthereisathreatthatneedstobeeliminated.Unlessthereisadedicatedrescuerandotherscanfocusonthethreat,thebestwaytokeepeveryonesafeistoneutralizethethreat.

TACTICAL FIELD CARE / INDIRECT THREAT

Youandthecasualtyareindangerbutnotimmediatelybeingshotat,areacrossthestreetfromtheburningbuilding.Goal?Keepthecasualtyaliveuntiltheevacuationphase.Bloodsweep,MARCH-exposethewoundsandtourniquet2-3”abovethem,recoveryposition,bettercover.What’stheevacuationplan?

MIST REPORT - Mechanism - Injury - Signs - Treatment

Forexample:Adultmalewithagunshotwoundtothethigh(mechanism),massivehemorrhage(injury)treatedwithasingletourniquethighandtight(treatment),followingcommands,palpableradialpulse(signs).

Equipment“Ihavenodisclosures.That’sbecauseIhateeverything.ButIwilltellyouwhatIthinkthebestsolutionis,whathasthemostdatatosupportitsuse.”

A 2• TACTICAL CASUALTY CARE1

REMEMBER

Decidewhatmedicalemergenciesyouplantobeabletomanage,obtainthosesupplies,andthenfindabagtofitthoseitems.

Suggested items for an Individual First Aid Kit (IFAK):

✓ Commerciallyavailabletourniquets-atleast2

✓CAT

✓SOFT-W

✓ Disposablegloves

✓ Kerlixgauzex2(4.5”x4.1yards)

✓ IsraelidressingorEmergencyTraumaDressing

✓ Medicalshears

PUBLIC ACCESS HEMORRHAGE CONTROL KITS

TheUSDepartmentofHomelandSecuritywouldlikeapublicaccesshemorrhagecontrolkitplacedalongsideeveryAEDinthecountry.Eachdevicemanufacturermakestheirownversionofthekits,andsothereisnoconsistencyastowhattypeoftourniquet(ifany)isinthekits.Manydocomewithhelpful,just-in-timeinstructions.

Somekitsevencomewithnon-rigidfabriclitters.

SuggestedSuppliers:

NorthAmericanRescue

TacMedSolutions

ChinookMedical

TramedicKits

North American Rescue

Tramedic

Scenarios“You’veknownhowtostopthethreat,nowyouknowhowtostopthedying.”

; 3• TACTICAL CASUALTY CARE1

FirstDayBackattheOffice

BreachGoneBad,orhand

inthewrongplaceatthe

wrongtime

MindYourManners

๏ Rule#1:Don'tgethurt.It'sbadenoughwehaveonecasualty.

๏ Lockthedoor,barricadeitifyoucan.

๏ Makesure911hasbeencalledorEMSactivated.

๏ Applythetourniquethighandtight:Thisiscareunderfire,wedon'thavetimetocutwindowsorsearchfortheholes.

๏ Bloodsweeptheneck&otherextremities.

๏ CheckA-R-C:Airway,Respiration,Circulation

๏ Hypothermiaprevention:whatcanyoudotokeepthecasualtywarm?Blanket?Coat?

๏ Pullthecasualtyaroundacorner,tocover,findasafeplacetoquicklyevaluatehim/her.

๏ Havesomeonecall911andactivatetheEMSsystem,he’sgoingtothehospital

๏ Inthisinstance,it’sprettyobviouswheretheinjuryis:Thathandlooksprettybadandthereisalotofblood.Tourniquetthewoundhighandtight(2-3”abovethewoundifyoufullyexposeit).

๏ Youcanminimizethearmfloppingaroundbypinningthesleevetohisshirt,orotherwisesecuringittohim.

๏ Gethimtothehospital.

๏ Rule#1ofTacticalCasualtyCareisdon’tgethurt.Don’tactlikeajerk&you’relesslikelytogethurt.

๏ Barringthat,thisismassivehemorrhageandneedstobedealtwithorthecasualtywillbleedtodeathinunder5minutes.GrabyourIFAK.

๏ Thiswoundistoohighforatourniquet,soitwillhavetobepacked.

๏ Youhavetogetthegauzetothesiteofthebleedinginsidethebody,itshouldfeellikeasquirtgunonyourfingertip.

๏ Continueputtingwadsofgauzeinthecavity,keepingpressureonit(ifusingCombatGauze,3-5minutesofdirectpressure).

๏ MakesureEMSor911hasbeenactivated,butyoucan’tdoituntilthemassivehemorrhagehasbeendealtwithbecausehecouldbleedtodeathwhileyou’reonthephone.

Conclusion“You’vebeentaughtRUN-HIDE-FIGHT,nowyouhaveanothertool:TREAT.”

G 4• TACTICAL CASUALTY CARE1

YouhavejustfinishedtheTacticalCasualtyCarecoursepresentedbyCrisisMedicineandtaughtbyMikeShertz,MD-18D.

Wehopeyou’refeelingempoweredtouseyournewskillstobea#ForceMultiplierForGoodinyourcommunity.

Thisisthehemorrhagecontrolflowsheetforallpre-hospitalmedicalproviderswhichissupportedbytheAmericanCollegeofSurgeonsandCommitteeonTrauma:

• Wantmoreinformation?Emailusatlogistics@crisis-medicine.comtofindoutaboutourin-persontrainingcourses,orcheckthewebsite,www.crisis-medicine.comforinformationonotheronlineclassesandupdates.

• FollowusonFacebook,@CrisisMedTrainingforupdatesandlinkstoinformationrelatedtothesetopics.

• Instagrammoreyourspeed?Yea,we’retheretoo.Crisismed_

• Wanttoencourageabuddytocometoclass?Havethementeryournameinthe“referredby”blankwhentheysignuptogetareferralgiftandourthanks.

• Thinkyouragency,school,workplaceshouldsponsoraclass?Shootusanemailaboutthattoo.Or,usethecontactformonthewebsitetoinquireaboutagency/institutionpricing.

NOTES:

Wanttocheckyourskillsagainstthe

guidelines?

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tactical casualty care - crisis medicine … · class workbook this is your printable pdf ﬁlled...

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