He has trained hundreds of Combat Medics, and thousands of Soldiers in the United States Army as well as foreign militaries. (Read full bio here)
Carl Denser co-owner of Apocalypse Medical Training & Readiness, AMTR, LLC is a former Combat Medic for both 5th Battalion, 3rd Field Artillery Regiments, as well as the 101st Airborne Division. (Read full bio here)
Trauma Treatment for the Apocalypse
In most American homes the average first aid kit is incapable of treating any degree of life threatening injury. Most commercially available first aid kits consist of a big, dusty, plastic box full of useless smaller boxes that contains expired bandages, and maybe headache medicine wrapped in child proof plastic. Even worse, at your workplace the ANSI (American National Standards Institute) and OSHA (Occupational Safety and Health Administration) compliant first aid kits are identically useless. Say you are a little above the curve and want to be ready for anything. You went online and bought an expensive “tacticool” medical kit to replace the plastic box in your medicine cabinet. Exactly what is in it? Do you know how to use the equipment? Have you run through stressful realistic drills to ensure proficiency? Most likely, your new medical kit will be just as useless without training and experience.
What do most people say when someone is injured? Call 911! Most of the Emergency Medical Services arrive within 10 minutes. This wait may be even longer if there are any circumstances that make the scene “unsafe.”
Average adult contains roughly 1.5 gallons of blood
The average adult contains roughly 1.5 gallons of blood. The heart can pump roughly 2 gallons per minute. So, now in front of you lays a person whose left leg has been amputated just above the knee, and bright red blood is spraying out of the severed artery with every heartbeat! How long does EMS have to arrive before that person dies!? I will give you the answer… they won’t. In fact, they likely won’t have a chance to start the ambulance. This human being laying before you is going to become unconscious in the next 45 seconds and die moments later.
When “evacuation” isn’t an option for life-threatening injuries
Some people pay money to be “trained” in Wilderness First Aid/First Responder, or they take an EMT course, or learn how to start an IV. There is a fundamental problem with the basis of these courses. They all focus on evacuation. Getting someone to a location, and ideally that location has medical staff and supplies.
What if there are no emergency medical services … anywhere?
What if no one is coming to help? What if there is nowhere left to take your patient? Ever. Your skills must go beyond splint in place, protect the cervical spine, make a litter and move the patient to safety. Also, unless you know how to perform a hasty whole blood transfusion, please don’t even let IV enter your mind. No one has been saved by an IV. I’ll explain more about this later.
Training students the same way as a combat soldier
At AMTR, we train our students in the same fashion as we would train a combat soldier. We utilize the MARCH protocol; which the military has proven over the last 15 years of war, prevents battlefield death. It does this by extending the “golden hour” of survival. We incorporate the MARCH protocol with the Tactical Combat Casualty Care Course, and add non-traumatic medical issues, pharmacology and how to manage these conditions indefinitely (until the patient is better… or dies… yes, people die).
MARCH is a massive improvement over the old “ABC or CBA” criteria. Some of you have heard about this, but it is truly THE must have fundamental of all initial trauma care. The heart is a pump. The pump develops pressure, known as blood pressure, and this pressure pushes our blood (hydraulic fluid) to our organs and brain. Lungs fill with oxygen rich air and provides a gas exchange to refill our blood cells with oxygen. Any disruption in this system, and we die. Remarkably quickly.
The first step in MARCH is “Massive Hemorrhage.” If there is a hole in the hydraulic system, there will be a massive drop in pump pressure and eventually death. We must plug the hole and stop the leak. If it’s an extremity, this means immediately applying a tourniquet. Yes, this is a major difference from civilianized first aid and EMT teaching. Many studies have dispelled the widespread belief that if you place a tourniquet the patient will lose the limb. In Iraq and Afghanistan, we placed tourniquets for hours and sometimes days, and many did not lose their limbs.What if the massive hemorrhage is in the groin or armpit? Obviously, a tourniquet is ineffective for a wound like this. There are some commercial items available to stop this bleeding. The “new kid on the block” is the X Stat which is essentially small sponges that are in a needless syringe that is injected into the wound. The sponges grow exponentially in the presence of blood and stop the bleeding.
Combat gauze and specialized tourniquets
Another option, and the most popular right now, is Combat Gauze. It is a type of rolled gauze impregnated with procoagulants that are packed into the wound as deep as possible. This is what the US Army currently uses, and it is extremely effective. There are also other clotting agents like Quick Clot, that work well, but are messy and full of complications. The good news is that all you need is some gauze, preferable rolled gauze. Just pack it in the wound until you can’t fit anymore, then hold pressure. Simple, cheap, and effective.A tourniquet can be made from almost anything, but some of the good commercially available ones are the CAT (Combat Application Tourniquet), SOFTT (Special Operation Forces Tactical Tourniquet), and RATS (Rapid Application Tourniquet System). You can also fashion one from a sturdy piece of cloth and a windlass (stick). The number one problem that I see when a patient arrives with a tourniquet: it’s too loose! Make sure you keep tightening until the blood stops, then one more turn for good measure. Keep in mind this will be painful for your patient; I always tell myself that ‘pain is the patient’s problem.’ If they live, the pain was worth it. Note: Never try to use a belt as a tourniquet. It will not work. It will pinch the skin, and it doesn’t even get tight enough to slow the bleeding.
Let’s talk about Airway
The second step in MARCH is Airway. If your patient can’t move air, then the body is unable to oxygenate the blood. This will cause the pump to increase its beats per minute, and will lead to death in a matter of minutes. The body can usually go for roughly four minutes before permanent damage is done to the brain and organs. To avoid those issues, you need to find a way to get air to the lungs. Try to reposition the airway, look for blockage.Depending on your equipment, you can try a supraglottic airway (easy to place tube down the throat to secure the airway) like the King LT. I am a fan of the King LT due to its ease of use. If you are trained and proficient with lots of experience intubating patients, endotracheal intubation is more effective (but it requires much more equipment and skill).
However, if you have minimal experience or are new to medicine, the King LT is nearly fail-proof. A study at the Army Medical Department Center & School in Fort Sam Houston, TX demonstrated this by having their new recruits place the airway with only 5 minutes of training. They had >99% first time successful placement of the airway device. And finally, some people advocate oropharyngeal airways or nasopharyngeal airways. Just personal preference here, but I hate them. In the MARCH protocol, they have no place. Either the patient is passing air, or they aren’t if they are I move on to Respiration.
Surgical airway when there’s no other option
Sometimes due to trauma or burns to the face, it is impossible to pass an airway. In very rare circumstances the airway is completely blocked. In this situation, if you have proper training, a surgical airway may be the only way to save your patient. Never attempt a surgical airway unless there is no other option and you have been trained extensively on how to perform the procedure. This is not television. If you stab a hole in their neck with a pocketknife and put a straw in the wound… they WILL die.You need to know the anatomy and procedure well. Note: Anyone can perform a surgical procedure with the proper skill, training, and experience to handle complications that inevitably arise.
Once you have an airway, you still need to move air in and out of the lungs. If there is a hole in the chest wall, the lungs will not be able to inflate. Any hole in the torso (from Adam’s apple to belly button) needs to be sealed with an occlusive (air-tight) dressing. You can get very nice commercially prepared chest seals, but this is not necessary. You can make one with a piece of plastic and tape.Some people are trained to only tape 3 sides to a chest seal, others are taught to tape all four sides. I teach the all four-side technique. I do this because chest seals do not like to stay on. I like to get them in place and not touch them again.
Another concern is that whatever put a hole in the chest may have also put a hole in the lung. If this happens, when your patient attempts to breathe, air travels through the hole in their lung and gets trapped inside the chest. After a while, this causes extreme pressure and discomfort. It can even press against the heart and prevent it from filling with blood in between beats. This is called a tension pneumothorax. There are a few treatments for this, but the simplest treatment is to lift a corner of your occlusive dressing to “burp” the chest and relieve the pressure, or you can use a technique called needle decompression.
Needle decompression is the term for the procedure in which you take a long IV needle (plus its associated catheter) and insert it through the chest wall to relieve the pressure. This technique works great on TV, but realistically it just buys you time. Another treatment is placement of a chest tube. I’m not going to go into detail about that in this article, but I do teach and train chest tube placement, monitoring, and removal in my week-long apocalypse medical training course. Note: Do not attempt a needle decompression or tube thoracotomy without proper training. If you don’t know how to do it, you will kill your patient.
Now on to Circulation. Is there hydraulic fluid in the pump? If so, is it enough fluid? Checking pulses will give you a rough estimate of this patient’s fluid status. If they have a radial pulse (the one at the wrist), then they have a systolic blood pressure >90 mmHg and I move on to the next step.If they do not have a radial pulse, then the discussion of an IV comes into play. Note: This is a heavily debated topic in medicine, so you may have heard other opinions than I present here. Based on my experience treating hundreds of multisystem trauma patients with various outcomes; as well as my trauma residency courtesy of Dr. Jeffrey Guy, I hate IV saline or ringers lactate in acute trauma treatment. (Note: Dr. Guy was the director of the regional burn center and acute operative services at Vanderbilt University Medical Center in Nashville. He also served as an associate professor of surgery, chief of the division of burn surgery, fellowship director of burn surgery, and course director of the critical illness immersion course at the Vanderbilt University School of Medicine.)
Body’s ability to compensate can come into play
I also base my view on the body’s ability to compensate during the first few hours of trauma. If I give fluids at this point and increase the pump pressure, I am diluting the red blood cells and clotting factors. While I may increase the pressure, I also impair the ability to carry oxygen and form clots. I may even cause previously formed clots to break free, causing the patient to bleed out and die.
Either do nothing or use whole blood
What do I recommend? Either do nothing or use whole blood. I’m not going to get into specifics on whole blood transfusion in this article, but an IV at this point is not advisable. If the patient makes it through the first few hours, and you want to start giving fluids judiciously that’s your call (and a training for another day). My opinion, your time is better spent moving on to hypo/hyper-thermia treatment and prevention.
Temperature regulation is commonly overlooked — don’t overlook it
One of the most overlooked parts of a trauma is temperature regulation. If you lose a liter or two of blood, you also lose all the heat that was in it. One of the first things that happens during a trauma assessment is removal of clothing to find the injuries. The body also shunts blood to the core and away from the arms and legs if there is significant blood loss.Consideration must be made to cover your patient as soon as possible, and keep them warm. Even if it is 100 degrees outside, a person who loses two liters of blood can go into Hypothermia (the H in the MARCH protocol, for those keeping track). Casualty blankets made of foil are simple, lightweight, and cheap.
The MARCH protocol can be accomplished very quickly, even in cases of very serious trauma. Training and experience will ensure proficiency when it matters. When you encounter a trauma patient:
1) Plug the holes,
2) Secure the airway,
3) Occlude holes in chest and monitor for tension pneumothorax,
4) check radial pulse and consider whole blood transfusion if you have been previously trained, and…
5) Keep them warm!
Medical supplies for trauma stabilization
Though I could write an article every week for the next year covering the subject of combat medical treatment, today’s article only covers trauma stabilization.To really start being ready for a time where there may be no doctors or hospitals due to any number of disasterous events, begin assembling a fully stocked trauma kit now to treat serious injuries, whether that’s someone in your family one day or someone else who needs your help.
2 Chest seals (Hyphin, H&H, or Halo)
2 Needle decompression (14 ga, 3in IV cathedars)
1Airway device (type depends on training)
3in Ace wraps
3 in cloth Tape
These are my thoughts on initial trauma stabilization and the MARCH protocol. These steps will keep most trauma patients alive, but this article alone is not enough. If you want to be prepared for anything, you need to train, a lot. If you want to become self-sufficient in any emergency, consider taking our week-long resident course. Check out our website www.apocalypsemtr.com DEPEND ON NO ONE™.