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Juliet Two

What Do You Really Need in Your Trauma Kit?

IFAK – What do you really need?

Let’s get started with a couple of combat medicine axioms that form the basis of all combat medicine dogma.

Combat Medicine Axiom #1  “Sometimes, the best medicine is fire superiority.”

Combat Medicine Axiom #2  “Good medicine at the wrong time is bad medicine.”

Since the Loadout Room is organized around first line, second line and third line gear, we’ll start our medic posts talking about first line medical gear.  The only first line medical gear you need is your IFAK. The trouble is, there are literally hundreds of variations of IFAKs to choose from and everybody has an opinion on what should go in it.  IFAK Manufacturer Rule #1 – The amount of shit they try to stuff in an IFAK is inversely correlated to their actual combat medicine experience.

What makes the IFAK useful is not its mere existence.  Good medicine is not just about equipment.  It’s not simply what’s in the bag of medicine that matters. It’s WHO is carrying it. Using an IFAK requires medical knowledge, simple skills, and the ability to decide when to use it.  See Axiom #2.

First, an IFAK is First line gear for YOU. It’s not for anyone else.  It serves as YOUR minimum necessary medical capability to save your own ass.  It is not a mobile ICU in a tacticool pouch.

Second, if you don’t ALWAYS train and deploy with an IFAK as first line gear for your own survival, stop reading right here and immediately apologize to your buddies for being “that guy”.  Then call your mom, husband or wife, kids, neighbors and grade school principal and tell them how you have been a complete dumbass, you have now seen the light and will forever more be squared away with respect to your medical skills and gear.

Moving on.

There’s a couple ways to decide what goes in your IFAK.

1.  The Academic Method:  Most preventable deaths on the battlefield (85% or more) are from uncontrolled hemorrhage (bleeding to death). So the academic would say that 85% percent of your IFAK gear should be for hemorrhage control. The next 9% are from pneumothorax (the proverbial sucking chest wound) so 9% of your gear should be for that….you get the picture.

That’s how most IFAKs have been stocked to date and it’s a decent standard.  However, combat death statistics change as combat medicine evolves.  A recent Committee on Tactical Combat Casualty Care (CoTCCC, more on that later) meeting included a review of several cases of soldiers who bled to death from wounds to the upper groin/pelvic area, and under the armpits.  They called these cases of “junctional hemorrhage” referring to the fact that the bleeding occurred in areas where limbs attach to the torso.  Historically, these cases of junctional hemorrhage were not considered preventable deaths because the bleeding couldn’t be controlled with a tourniquet and direct pressure on the bleeder wasn’t possible.  Today, with certain field surgical techniques taught to medics and a soon to be released abdominal aortic tourniquet, future deaths from these types of injuries may be classified as preventable.  The Academic Method and your IFAK become susceptible to mission creep.

2. The Packrat Method: “If two is one and one is none, then six should do the trick!”.

This method ignores axiom #1, “The best medicine is fire superiority”.  Unless otherwise ordered, never sacrifice ammo for more band-aids.  Bill, a SOFREP founder, always says he never wants to die from lack of ammo.

3. The Boy Scout Method: Be Prepared! “I’ll just throw in a few ibuprofen, a couple decongestants, a sling, some burn cream, and some moleskin just in case”.  Again, think FIRST LINE GEAR. None of that shit will save your life. If you want something for the sniffles, blisters, or joint pain, put it in your ruck.

First line gear relates directly to first line medical skills.  If nothing else, you must be able to stop bleeding.  Learn how to do this and then use the materials you’re familiar with.  You will want to make sure your IFAK has a roll of some type of gauze, (ideally a hemostatic gauze)and a combat rated tourniquet.  That’s the minimum. Lastly, place your IFAK in a location on your body where you can reach it with either hand in case one of your limbs is unusable.

Juliet 2

Medical Fundamentals

We’ve had several requests for more medical articles.  In order to do this justice, we have to keep in mind a few fundamental truths about medical care in austere conditions.

1.  Do no harm. – Good medicine at the wrong time is bad medicine.  Obtain good training in how and when to apply medical care.  Start with a self-aid/buddy-aid program and build your skills from there.

2.  Prevent Injury – An ounce of prevention is worth a pound of cure.  In combat this may mean that we defer medical care until after the threat has been eliminated.  The old adage of “the best medicine is fire superiority” comes to mind.  Beyond bullet wounds and explosions, avoid misery and illness by dressing appropriately for conditions, avoid dehydration, and use appropriate protective equipment (eye protection, gloves, body armor, etc).  If you train with live fire, be sure to appoint a safety officer and make sure he or she is not included in the scenario.  Good people die in training from preventable errors.  Always follow the strictest safety practices when training with any kind of weapon system.

3.  Shock is the enemy.  Preventing shock is key to survival.  Get life saving care started as soon as possible, even if you have to treat yourself (self-aid).  A previously healthy body will immediately start trying to offset the changes caused by an injury.  Early on, these processes are helpful.  In cases where severe injury or significant delays in care occur, these internal processes can spiral out of control and survival becomes less likely.  Get yourself a good tourniquet and some hemorrhage control training and be ready to act immediately.  I also recommend learning CPR and knowing how to treat choking and near-drowning.

4.  If shock doesn’t kill you, infection might.  Infection begins at the time of injury.  Any disruption in the natural barriers of the body (skin, mucous membranes) allows nasty bugs already on the skin and in the environment to set up infection.  Do everything you can to avoid adding to the burden of infection.  Survival decreases rapidly when you combine deep shock and infection.

5.  Err on the side of caution.  When circumstances permit, have a trained medical provider evaluate an injury as soon as possible.  It can save trouble down the road.

6.  Know how to access the emergency system no matter where you are.  A good sheepdog always has an exit strategy.  Take a little time to figure out your medical contingency and emergency plans.  Medical emergencies place huge demands on attention and delays can cause irreversible injury or death.  Trying to figure out your emergency plan in the middle of a crisis just plain sucks. Get comfortable with the emergency resources in your area and know how to activate them.

 

Juliet 2

The MacGyver Cric | Special Operations Medical Magic

Next time you are hanging out, happen to have spare airway tubes and IV sets sitting around, and want to impress your medical geek friends with some SOF Medical Magic, throw together a MacGyver Cric.  It’s a great conversation starter if not a great airway…..

The following story highlights a bit of SOF medical gadgetry. Lots of folks have heard of this bit of medical coolness, few have actually used it.

The usual disclaimers apply – this is not medical advice.  As configured, the equipment demonstrated in this article isn’t approved by any medical authority, is not FDA approved, and has not been studied in any controlled manner.  Suffice to say, this is off-the-record, no shit hasty and temporary.

This is graphic……and, oh by the way, this never happened.

A long time ago, in a galaxy far far away……I was part of a medical team that treated an adult male after he attempted to kill himself with his personal weapon.  He did the typical Hollywood drama shot, with the pistol pointing vertically while he held it under his chin.  He fired one round that shredded his jawbone and lower face.  Sadly, he missed his brain entirely and survived.  (Its tragic that he tried to kill himself in the first place, it just got worse when he missed…)

Without any bony structure, his lower face and blood kept falling back into his throat, choking him.  He was terrified, in severe pain, and desperate to die.  Worse yet, every time we tried to lay him down to put in a breathing tube, he’d choke more and start swinging and kicking us.  We couldn’t get close to the guy’s neck to perform a surgical airway without getting kicked and punched.  Not knowing where the bullet had traveled, we decided that a blind insertion of any kind of tube through his face could possibly penetrate his brain.  Fortunately, the patient could sit up, lean forward, and hold the shreds of his face out of the way to get a short breath on his own. (It’s amazing how a person will protect their own airway if allowed).

This guy was in a bad way and we were in a bind.  There are only a couple airway maneuvers you can use when you can’t lay a person flat.  They require a very cooperative patient, an anatomically intact airway, and no risk of riding a bullet tract into the brain.  We had to “cric” the guy but we couldn’t get close to his neck and no one wanted to be punched while holding a scalpel.

The challenge – perform a cricothyroidotomy while the patient is sitting up and swinging his fists at you.

Normally, to perform a cricothyroidotomy you make an incision in the skin of the neck and put a tube into the trachea through a little membrane that stretches between the cricoid cartilage and the big thyroid (voice box) cartilages.  I usually do this on severely sick or injured people with massive facial trauma or airway swelling when standard airway techniques fail.  These folks are almost always lying down and unconscious.  It wasn’t gonna be easy or safe to use a scalpel to make a small incision and insert tiny instruments into the neck of an arm swinging, blood slinging, desperate and dying man.

THIS PART IS OFF THE RECORD. IT NEVER HAPPENED AND WILL BE DENIED BY ALL WHO WERE PRESENT

We wanted to be able to shield the patient from the sharp end of the airway device while we got up nice and close to his neck without getting hit.  We needed something other than a scalpel or long needle to punch a hole in his neck, get air moving into his lungs and give us the time we to sedate him and place a proper airway.

Enter the “MacGyver Cric”…….

This is not an approved airway by any measure but it does provide one alternative for when you don’t want to wrestle a guy while holding a scalpel and you need the control of a short poker with the airflow capacity of a standard airway device.

To make the  “MacGyver cric” we used a standard 7.0 endotracheal tube and a macro-drip IV tubing set. (10 gtt/ml).   We assembled our equipment including the bag valve mask and standard surgical cric kit.  We then explained our plan to the patient who agreed to hold as still as possible.  We involved him in the plan and that helped to calm him down.  We had two strong guys hold his hands and keep his legs on the table.  Once things were set I got right up to his neck with my fist and quickly inserted the pointy end of the IV set into his neck.   The effect was dramatic.  His breathing became more controlled and he calmed down.   Once he had a functioning (temporary) airway, we could safely sedate him and control his pain.  Once he was asleep, we changed the Macguyver cric to a standard cric by using a wire-guided technique similar to other tube changing maneuvers.  Once the approved airway was secure we initiated his evac and sat down to write our notes…..together….in a coordinated kinda way…..ya dig?

To make a “MacGyver Cric”  –

  • Step 1  Cut the 7.0 Endotracheal tube at a right angle to its long axis at the 20 cm mark.  Keep the short end with the adapter, get rid of the end with the balloon on it.  You don’t need it.
  • Step 2.   Cut the IV Extension set drip chamber at a right angle halfway between the puncture set and the IV tubing.  Keep the pointy end, get rid of the IV tubing.
  • Step 3.  Jam the cut end of the endotracheal tube into the sleeve created by the cut end of the drip chamber.  The internal diameter of the 7.0 airway tube makes a tight fit over the external diameter of the internal drip cap.
  • Step 4.  Place the “needle end” hasty cric into the same place YOU were TRAINED to place a cricothyroidotomy.  (the small soft space under the adam’s apple, above the cricoid cartilage and below the thyroid cartilage)

Caution: When you perform a cricothyroidotomy of any type, you are pushing a sharp object into the neck of another human being.  The risk of puncturing big arteries, big veins, the back wall of the trachea, the esophagus, the soft tissue spaces around the neck and other disasters is quite likely.  Don’t do this unless….

Juliet 2

Doc Up! – Introducing Juliet 2

Juliet 2 contributors include several authors whose medical experience ranges from current and veteran special operations medics, corpsman, PJ’s, physician assistants to board certified physicians.  Each contributor’s medical experience includes field experience in special operations medicine.  The Juliet 2 call sign protects the privacy of the contributors and their current patients, the sensitive nature of certain contracts they support and the special relationship these care providers have with the men and women they serve. This is an honor and a privilege.

First off let me take a minute to thank Brandon, Jack and Bill for the opportunity to contribute to SOFREP’s Load Out Room.  Our friendships, in some cases, go back all the way to BUD/S, others started in any number of forgettable locations across the globe.  Thanks for creating SOFREP and for giving us another place to use big words.

Let’s set a couple ground rules.

  1. We won’t drown you with esoteric medical bullshit.
  2. Our posts will include a general reference to the medical credentials of the author (18D, PJ, PA, MD, etc).  This isn’t about whose brain is bigger.  We all do our part.
  3. We’re the docs. We’re used to people believing everything we say. Don’t do it. Challenge us.
  4. We will tell you the medical facts, as we know them.  Half of what we tell you will be proven wrong in time.  We just don’t know which half.
  5. When there is ongoing professional debate about a medical topic, we will highlight the debate, pick a side, and defend our position until death or bedtime…whichever comes first.
  6. Nothing in these medical posts constitutes medical advice, medical practice guidelines or the opinion of your unit’s medical command.  God help you if you get that confused.

Juliet 2

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