RescueRanger
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Continuing on from my previous posts on first aid an emergency response today's post will focus on immediate action drills for IED incidents. As always, I hope you never have to use these skills but in-light of recent emerging trends these are lifesaving skills that can help you or enable you to help others in the worst case scenario.
The Response
The first thing that needs to be mentioned is to know the enemy’s TTP (Tactics, Techniques and Procedures.) That being said, they often set up secondary devices with the hope of taking out first responders. Take that second to look around the scene, not only for other threats, but to determine ground zero of the incident. Time, distance and shielding goes into play as well. We need to look for the victims that are in the worst shape, not necessarily the ones yelling the loudest.
What should you expect to see if you respond to an IED? Let’s use the injuries from the Boston marathon. Partial or complete amputations, patients near the blast suffered burns which causes a compromised airway, penetrating trauma to the chest wall and lungs. It doesn’t matter if it’s an explosion or gun shot wound, we’ll have the same response. That response that we’ll go over today is MARCH, specifically focusing on the first three issues to address.
M – Massive Bleeding
A – Airway
R – Respiration
C – Circulation
H – Head injury/Hypothermia.
Controlling that bleed:
The textbook answer to control bleeding is to activate 1122 first and transport to higher medical care. In the real world, massive bleeding needs to be controlled immediately. The ideal way to do this is with a tourniquet.
A manufactured combat tourniquet is the best option. When it come to massive bleeding from an extremity, you can’t go wrong with a tourniquet. We have massive amounts of data in tourniquet use over the past ten years and it all says the same thing, TOURNIQUETS SAVE LIVES.[1]
Tourniquet placement is crucial, go as high on the limb as you can. It doesn’t matter if its a gun shoot wound or an IED. Bullets and shrapnel can travel and tear flesh up above the apparent wounds.
Remember that arteries are elastic in nature and when severed, they travel up into the muscle. I think this was best shown in this clip from Black Hawk Down:
Tighten the tourniquet until you see the bright red blood stop. This will be extremely painful and be aware that the patient may try to loosen it to relieve the pain.
If you don’t have a tourniquet it’s OK. A field expedient tourniquet can be made from a piece of cloth that’s two inches wide and a stick to act as a windlass to tighten it. Army cravats are small and work awesome in a pinch. If you don’t have a tourniquet it’s OK. A field expedient tourniquet can be made from a piece of cloth that’s two inches wide and a stick to act as a windlass to tighten it.
Here you can see we have made an improvised tourniquet using two strips of cloth and a pair of scissors as a securing mechanism:
We are also observing the patient as they move to a position of comfort, especially with head trauma. If they need to sit a certain way to breathe, let them.
Look for soot around their mouth and nose indicating a compromised airway. These patients can go downhill quickly if unnoticed. They will experience swelling of the vocal cords and eventually will lose the ability to breath on their own. They need ALS (advanced life support) now.
With blast injuries, we’re concerned about penetrating trauma to the lungs and the thoracic cavity. You’ll need to do a thorough assessment if you’re looking for very small shrapnel wounds. More than likely you’ll see no blood coming from these wounds, so use your hands and stretch the skin to expose hard to spot wounds.
This is an example of a Rapid Trauma Assessment you can perform on an injured casualty.
If you do find any wounds, you’ll need to place an airtight seal over it to prevent air from entering the chest cavity. Ideally this is a pre-manufactured chest seal like the Asherman (tm)Chest seal - these are rare to come by in Pakistan, but plastic bags will work also. When using plastic, remember to tape off three sides and leave one corner untapped to allow for air to escape, this prevents a medical complication known as tension pneumothorax (collapsed lung).
The above picture is to get you thinking. How would you handle a situation like this, who would you help first? Events like this will never be a cut and dry exercise. If this would have been your town, how long would it be until help arrived? Is help coming? Rescue 1122 response time is between 5 and 7 minutes. Remember that.
Take your fully stocked med bag or kit out of the equation for a moment and think outside the box, “what can I use to treat the injured if I didn’t have my kit?” In care under fire, we only do the M and A (controlling massive bleeding and opening the airway). That will buy you time, so do you go from one casualty to another controlling bleeding and managing the airway? I’d say yes. We need to be the most help to the most people. I don’t want one alive casualty that is all neat and bandaged up, when I could have performed the important steps for more people.
How would you handle a bystander that wants to help, but may know nothing about a medical first response? While he doesn’t have a clue what to do, give him a specific job as this will allow you to do your assessment.
It’s easy to look at what happened in any situation and say I’d do this, or they didn’t do this. We live in a dangerous world, it could be an IED attack or a shooting.
References:
Lee C, Porter KM, Hodgetts TJ, Tourniquet use in the civilian prehospital setting, Emergency Medicine Journal 2007;24:584-587.
Thank you for taking the time to read this. If you have enjoyed reading this post why not consider reading my other posts:
The Response
The first thing that needs to be mentioned is to know the enemy’s TTP (Tactics, Techniques and Procedures.) That being said, they often set up secondary devices with the hope of taking out first responders. Take that second to look around the scene, not only for other threats, but to determine ground zero of the incident. Time, distance and shielding goes into play as well. We need to look for the victims that are in the worst shape, not necessarily the ones yelling the loudest.
What should you expect to see if you respond to an IED? Let’s use the injuries from the Boston marathon. Partial or complete amputations, patients near the blast suffered burns which causes a compromised airway, penetrating trauma to the chest wall and lungs. It doesn’t matter if it’s an explosion or gun shot wound, we’ll have the same response. That response that we’ll go over today is MARCH, specifically focusing on the first three issues to address.
M – Massive Bleeding
A – Airway
R – Respiration
C – Circulation
H – Head injury/Hypothermia.
Controlling that bleed:
The textbook answer to control bleeding is to activate 1122 first and transport to higher medical care. In the real world, massive bleeding needs to be controlled immediately. The ideal way to do this is with a tourniquet.
A manufactured combat tourniquet is the best option. When it come to massive bleeding from an extremity, you can’t go wrong with a tourniquet. We have massive amounts of data in tourniquet use over the past ten years and it all says the same thing, TOURNIQUETS SAVE LIVES.[1]
Tourniquet placement is crucial, go as high on the limb as you can. It doesn’t matter if its a gun shoot wound or an IED. Bullets and shrapnel can travel and tear flesh up above the apparent wounds.
Remember that arteries are elastic in nature and when severed, they travel up into the muscle. I think this was best shown in this clip from Black Hawk Down:
Tighten the tourniquet until you see the bright red blood stop. This will be extremely painful and be aware that the patient may try to loosen it to relieve the pain.
If you don’t have a tourniquet it’s OK. A field expedient tourniquet can be made from a piece of cloth that’s two inches wide and a stick to act as a windlass to tighten it. Army cravats are small and work awesome in a pinch. If you don’t have a tourniquet it’s OK. A field expedient tourniquet can be made from a piece of cloth that’s two inches wide and a stick to act as a windlass to tighten it.
Here you can see we have made an improvised tourniquet using two strips of cloth and a pair of scissors as a securing mechanism:
Airway
First thing is to talk to the patient. If they answer, they have a good airway (for now.) If they have a compromised airway, you’ll have to try and open it. Head tilt, chin lift or the jaw thrust.Look for soot around their mouth and nose indicating a compromised airway. These patients can go downhill quickly if unnoticed. They will experience swelling of the vocal cords and eventually will lose the ability to breath on their own. They need ALS (advanced life support) now.
Respiration
The third thing moving down our MARCH list is Respiration. This area is the neck down to the belly button on all sides.With blast injuries, we’re concerned about penetrating trauma to the lungs and the thoracic cavity. You’ll need to do a thorough assessment if you’re looking for very small shrapnel wounds. More than likely you’ll see no blood coming from these wounds, so use your hands and stretch the skin to expose hard to spot wounds.
If you do find any wounds, you’ll need to place an airtight seal over it to prevent air from entering the chest cavity. Ideally this is a pre-manufactured chest seal like the Asherman (tm)Chest seal - these are rare to come by in Pakistan, but plastic bags will work also. When using plastic, remember to tape off three sides and leave one corner untapped to allow for air to escape, this prevents a medical complication known as tension pneumothorax (collapsed lung).
The above picture is to get you thinking. How would you handle a situation like this, who would you help first? Events like this will never be a cut and dry exercise. If this would have been your town, how long would it be until help arrived? Is help coming? Rescue 1122 response time is between 5 and 7 minutes. Remember that.
Take your fully stocked med bag or kit out of the equation for a moment and think outside the box, “what can I use to treat the injured if I didn’t have my kit?” In care under fire, we only do the M and A (controlling massive bleeding and opening the airway). That will buy you time, so do you go from one casualty to another controlling bleeding and managing the airway? I’d say yes. We need to be the most help to the most people. I don’t want one alive casualty that is all neat and bandaged up, when I could have performed the important steps for more people.
How would you handle a bystander that wants to help, but may know nothing about a medical first response? While he doesn’t have a clue what to do, give him a specific job as this will allow you to do your assessment.
It’s easy to look at what happened in any situation and say I’d do this, or they didn’t do this. We live in a dangerous world, it could be an IED attack or a shooting.
References:
Lee C, Porter KM, Hodgetts TJ, Tourniquet use in the civilian prehospital setting, Emergency Medicine Journal 2007;24:584-587.
Thank you for taking the time to read this. If you have enjoyed reading this post why not consider reading my other posts:
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