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Survive Injuries Until Backup Arrives

Written by Paul Shubinsky

Just because we become injured, it doesn’t mean we have lost the fight. It just means that we need to end the fight more quickly and decisively so that we can tend to our wounds. The two most preventable causes of death in combat are caused by penetrating trauma (the type of wounds caused by guns and edged weapons).

The human body is capable of continuing on despite almost unimaginable punishment. This combined with a combat mindset will go a long way to ensure your survival. The Medal of Honor Citation of Master Sergeant Roy Benavidez is an excellent example of this. It is May 2, 1968, in Loc Ninh, South Vietnam…

“Prior to reaching the team’s position, he was wounded in his right leg, face and head. Despite these painful injuries, he took charge. When he reached the leader’s body, Sergeant Benavidez was severely wounded by small arms fire in the abdomen and grenade fragments in his back. Although in extremely critical condition due to his multiple wounds, Sergeant Benavidez secured the classified documents and made his way back to the wreckage, where he aided the wounded.”

Adrenaline is a powerful drug produced by our bodies during combat. It gives us the strength necessary for fight or flight. It makes us stronger, faster and more tolerant of pain when necessary. It causes our surface blood vessels to constrict, keeping blood circulating to our more vital organs such as the heart, lungs and brain.

We often won’t even be aware of the injuries we have sustained until the fight is over. People who have been stabbed often report that they thought they were only punched, or didn’t realize they were stabbed until they saw or felt the blood.

Once we have won the fight and are sure no further threat exists, we can assess ourselves and our partners for life-threatening injuries and treat any wounds with our personal medical kits. This should be done as soon as safely possible, as major bleeding can cause death in as little as three minutes. The average response time for an ambulance in the city of New York is more than six minutes. In well-populated rural areas, this can be 20 minutes or longer.

The medical kit should be carried at all times and contain a tourniquet, a trauma dressing, an occlusive dressing, a hemostatic Occlusive dressing improvised from a plastic sandwich bag. A corner is left un-taped to allow for the escape of air. agent and a nasal airway. This equipment will treat the three most common causes of preventable combat death: extremity hemorrhage, tension pneumothorax and airway obstruction. These items can be carried in a cargo pocket, a small pouch on your duty belt, or behind the trauma plate on your vest. The equipment in this kit is intended to treat you. If your partner is injured, use his kit to treat him.

By incorporating the use of your medical kit into your training and “what if” scenarios, you can become as proficient with this lifesaving equipment as you are with defensive tactics and your firearm. The incorporation of medical scenarios along with your tactical training will also help you to find a suitable location to carry the kit. This may vary from agency to agency, depending on what other equipment you carry. Determine whether you can access the kit while sitting in your patrol car or while prone, and think about what other equipment might get in the way. The location of the kit can then be standardized within your agency.

Practice accessing your equipment under various realistic, stressful conditions. Practice using the kit, and the equipment, using your weak hand only and strong hand only to simulate an injury. If kits are issued without realistic training, they may not be used when they are needed most. We fight as we train, and if we don’t train to self-treat life-threatening injuries under stress, we may die with the kit in our pocket because we never trained to use it.

When injured, we must rapidly assess ourselves in a systematic fashion and correct any problems as we find them. Are we hemorrhaging (bleeding to death)? A good combat tourniquet will quickly control a hemorrhage from an extremity. The CAT® and SOF® were both proven to be 100 percent effective during U.S. Army Institute of Surgical Research testing.

Blackhawk® offers the I.T.S. (Integrated Tourniquet System) line of apparel; this is tactical wear with two built-in tourniquets per extremity. Tourniquets are properly applied by tightening the strap around the injured extremity and turning the windlass until bleeding stops, or until you can no longer feel a pulse in the extremity. In most law enforcement scenarios, you will receive definitive care in a hospital long before any permanent damage is done from the tourniquet itself.

For areas of the body where a tourniquet will not work (i.e., the abdomen), wounds should be packed, and direct pressure, pressure dressings and hemostatic agents should be used to control hemorrhaging. When applying self-aid, direct pressure can be applied by using your hand. It may be necessary to stick your finger into a wound to compress bleeding arteries or veins.

Pressure dressings like the Cinch Tight®, Emergency Trauma Dressing ETD™ or Israeli Dressing are also effective in controlling bleeding. They combine a bulky dressing with an elastic bandage. They are able to be applied tightly and secured in place. If bleeding continues, additional dressings can be applied on top of the first.

If available, hemostatic agents can also be used. Agents such as Wound Stat™, HemeCon® and Quick Clot® control bleeding by promoting clotting or forming a barrier over the surface of the wound. Tactical Combat Casualty Care Guidelines recommend applying Quick Clot® Combat Gauze™ along with two minutes of direct pressure to areas where bleeding can’t be controlled with a tourniquet. Combat Gauze™ can be used to pack deep wounds. This offers an advantage over standard packing because it also promotes clotting.

Combat or tactical breathing, a technique already used by many in law enforcement to control heart rate during high stress situations, may also help us if we are bleeding. It is described by Lieutenant Colonel Dave Grossman in his book “On Combat” as “an easy-to-do technique that can be used in a stressful situation to slow your thumping heartbeat, reduce the tremble in your hands, deepen your voice so you don’t sound like Mickey Mouse, and to bathe yourself with a powerful sense of calm and control.

“In other words, it is a tool to control the sympathetic nervous system.” By reducing our heart rate and blood pressure through tactical breathing, we reduce the volume of blood being pumped through our heart each minute. This means we will be hemorrhaging at a slower rate, and it will be easier to control.

Tactical breathing is done by taking a deep breath in through the nose for a count of four while expanding the abdomen, then holding the breath for a count of four, and exhaling through the mouth for a count of four. At the end of exhalation, you pause for a count of four prior to inhaling again to repeat the cycle. The number of cycles needed to achieve the desired effect will vary from person to person. This technique should also be incorporated into your training routine.

Are we breathing OK? Do we have any penetrating wounds to our chest? Is there movement of air through any of these wounds? A penetrating wound to the chest that has air moving through it, or is bubbling when you breathe, is referred to as a sucking chest wound. An occlusive dressing needs to be applied to this type of wound to prevent air from entering through it and developing into a tension pneumothorax.

A tension pneumothorax occurs when air enters the chest cavity but does not escape. Pressure builds up, compressing the lungs and heart. This can quickly become fatal. Signs and symptoms of a tension pneumothorax are anxiety, difficulty breathing, rapid shallow respiration, rapid heart rate, unequal chest rise and tracheal shift.

The occlusive dressing should be applied directly over the wound at the end of exhalation. This should be taped on all sides, leaving a small portion un-taped to allow air to escape, but not allowing air to re-enter through the wound. Some commercially available chest seals, like the Asherman® Chest Seal, have a one-way valve for this purpose.

In the event of facial trauma or unconsciousness, your airway can become compromised. The insertion of a nasal airway will help to keep it patent in the event that you lose consciousness. A nasal airway is a trumpet-shaped tube which is inserted through a nostril into the back of the throat. This tube provides a passageway for air and prevents the airway from becoming obstructed by the tongue in the event of unconsciousness.

Winning the fight is half the battle. Once the fight is over, we can focus on our survival. We should have a personal medical kit with us at all times. We need to incorporate the use of our medical equipment into realistic training scenarios so that when injured, we will instinctively begin to treat our injuries. A rapid assessment and the rapid application of self-aid will help prevent death from the most common life-threatening injuries sustained in combat (extremity hemorrhage, tension pneumothorax and airway obstruction), so that we make it back home.

Paul S. Shubinsky is a certified emergency nurse. He has worked in the field of emergency medical services in New York City for the past 19 years. He spent several years working as an EMT and has worked as a registered nurse in level one trauma centers for the past 16 years.

Published in Tactical Response, Sep/Oct 2010

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