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Most who visit this site are well aware that calling upon the aid of others in a desperate situation can take anywhere from minutes, to hours or days for that aid to arrive. I assume this is perhaps the primary cause of your arrival at this website; you are aware of one simple fact… you alone, are the first line of defense when it comes to the safety of yourself and your family. Just as many of us have trained hard in the defensive arts, we must also be prepared to assess and provide first aid for any unfortunate injuries that may result from an armed confrontation.

The following post will cover the basics of combat trauma first aid; specifically focusing on firearm and bullet shrapnel injuries. Since I am not an EMT or a military medic, I have enlisted the consult of a colleague of mine for medical guidance and editing to ensure accuracy; he is a retired US Air Force Medical Technician who served in the Gulf War (’90-’91) and has treated numerous civilian and military combat casualties throughout his career. He knows his stuff, and now you will too…

Before we get started, we have to be clear about one piece of reality that has been painfully distorted by Hollywood tough guys over the years; if you get shot, you will most likely need immediate medical attention if you are going to survive. Even hits in non-vital areas can result in death by bleeding, infection and/or shock. So the purpose here is not to learn how to play do-it-yourself doctor, but more-so to survive long enough to get to a real doctor.

DISCLAIMER: Perform the following tasks to save a life, and do so at your own risk. As always, Brasstard.com will not assume any liability for your actions.

IMPORTANT: If possible, make sure the scene is secure before treating any casualties. You will be of no assistance to the fallen if you become one of them. Be aware of your surroundings at all times. If possible, call emergency services immediately (before providing first aid) and follow their instructions.

Step One: Injury Assessment

You must determine the location(s) of all entry and exit wounds. Your victim might have sustained multiple hits, and it is crucial to determine which of those will have the most immediate effect on their survival. You will need to have a decent knowledge of human anatomy to be fast and effective in this stressful situation. So study up… know where the vital organs are located and where the major blood vessels are found.

Commander, US Pacific Fleet – Flickr User – ©2011

If you have more than one casualty, you must perform Triage in order to decide which to treat first. In its simple form, Triage refers to the sorting of patients into the following three categories…

  1. Those likely to survive regardless of medical care administered
  2. Those likely to expire regardless of medical care administered
  3. Those likely to survive if given immediate medical care

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Priority is generally given in the following order, 3 then 2 then 1. Those with major injuries, who are likely to survive with immediate intervention come first. Those with major injuries, who are unlikely to survive come second. And those with only minor, or non-life threatening injuries come last. The US Army and American emergency rooms in general have even more subsections for triage. However, the main three should suffice for providing life-saving first aid in the field.

Step Two: External Bleeding Assessment

You must immediately determine the type and the severity of the bleeding;

  1. Arterial Bleeding: Bright red and spurting bursts of blood that coincide with the heart beat
  2. Venous Bleeding: Dark red, oxygen-depleted blood that flows more evenly
  3. Capillary Bleeding: Dark red and slowly oozing blood or bruising that often clots on its own

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Step Three: Control External Bleeding

After you have determined the type and severity of the bleeding, you must take steps to control it.

  1. Isolate body substances by wearing protective gear such as latex gloves, safety glasses and face masks if possible
  2. Apply direct pressure to the site of the bleeding. If direct pressure to the area fails to stop the bleeding, you may have to reach into the wound and pinch the severed vessel with your fingertips, or preferably a hemostat.
  3. If the injury is on an extremity, elevate it to decrease the blood pressure in the injured area. You may also apply pressure to the femoral artery (groin) or the brachial artery (inner bicep) to slow blood loss in the legs or arms respectively.
  4. If the injury includes bone damage, immobilize the extremity by making a field expedient splint to prevent further vascular damage from sharp splintered bone
  5. If available, apply a clotting aid such as Quik-Clot gauze, then wrap with field dressing and continue to apply direct pressure
  6. As a last resort, and only after all other methods have failed, apply a tourniquet to an amputated limb
Pearson Scott Foresman – Undated

IMPORTANT: The general guideline according to the US DOT EMT-Basic National Standard Curriculum is that tourniquets should not be used on anything other than an amputated limb, and only as a last resort. They are designed cut off all circulation to the affected area, and when left in place for extended periods of time will result in severe necrosis of everything beyond the tourniquet. Permanent damage to a limb can occur in as little as 45 minutes. This is why they are not recommended unless all other attempts to control bleeding have failed.

A tourniquet should be at least two inches wide, and be placed about two inches above the injury. It should never be placed directly over a joint, or on any body part other than a limb. Once applied, it should not be removed until the patient reaches a hospital. If a tourniquet is removed in the field, it can cause blood poisoning and lead to septic shock as infected blood is released back into the core of the body. Always document the time the tourniquet was applied, be sure it is applied securely, communicate its location to responders, and make sure it is easily visible at all times.

Step Four: Address Breathing Problems

The disruptive power of small arms can cause serious respiratory damage. One of the most common is the “sucking chest wound”.  This occurs when a projectile pierces the chest and results in a partial or complete collapse of one or both lungs. As the patient attempts to breathe, the collapsed lung sucks air in through the wound into the thoracic cavity.

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This can be temporarily alleviated by applying a sterile occlusive dressing over the wound and securing it on 3 of the 4 edges and corners with medical tape. This creates a sort of makeshift valve that allows air to exit the cavity without letting more air in. Once the dressing is in place, cover the patient with blankets to alleviate shock and arrange immediate transport to a trauma surgery facility.

Providing first aid for a gunshot wound to the head, neck or face is particularly challenging. This is partly due to the high chances that the injury has obstructed or destroyed the airway. You will not only have to control the external bleeding, you will also have to establish an airway.

You may have to perform an emergency tracheostomy in the field to create an airway. Despite your favorite actor making it look so simple on TV, this is a fast-paced, precision task that can be tricky under extreme stress. The neck is highly vascular, so cutting in the wrong place can lead to profuse bleeding. Also, the cutting is done in layers and should not be too deep as to avoid a complete perforation of the trachea. Furthermore, without a proper trach tube and sterile suction device, makeshift breathing tubes can quickly become clogged by mucus, blood or other fluids. For these reasons, I am not going to cover it in detail here.  There are however, some good medical videos on the Internet that show the procedure in detail for the inquiring mind in you.

Step Five: Identify and Assess Internal Bleeding

The most common cause of internal bleeding is blunt force trauma. In the world of firearms, this can happen if you take some fire while wearing Kevlar. The projectile may not penetrate your skin, but you still bear the full force of hundreds or even thousands of ft/lbs of energy striking your body in an instant. Taking a 1-oz lead 12-ga slug at 10 yards while wearing soft body armor is akin to taking a full-swing hit in the chest by a sledge hammer. Needless to say, the results can be devastating if not assessed and treated properly.

For obvious reasons, internal bleeding can be much harder to assess and treat than external bleeding.

Signs and Symptoms

  1. Pain, swelling, tenderness or discoloration of the injured area
  2. Bleeding from mouth, rectum, vagina, or other orifice
  3. Vomiting bright red blood or dark reddish-brown blood
  4. Dark, tarry or bloody stool
  5. Tender, rigid or bloated abdomen

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Further Signs that Indicate Possible Shock (Hypoperfusion)

  1. Anxiety, restlessness or other psychological disturbances
  2. Weakness, faintness or dizziness
  3. Excessive or prolonged thirst
  4. Pail, cold and clammy skin
  5. Dropping blood pressure, high heart rate and/or weak pulse
  6. Dilated or slowly-responsive pupils
  7. Nausea and/or vomiting

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Treating internal bleeding in the field is near impossible without the right equipment. Even with the right equipment, you are merely buying some extra time to get the patient to a proper medical facility. If the person is in shock, you need to establish and maintain an airway. You may also need to apply positive-pressure ventilation and even high-flow oxygen to enrich what little blood is still flowing properly. The patient will likely need surgery to relieve the pooling of blood in the internal cavities and repair damaged vessels and organs.

Step Six: Treat the Shock (Hypoperfusion)

Your best bet to alleviate internal bleeding symptoms in the field is to treat the shock (hypoperfusion) and keep the patient breathing on their own. Keep the patient from going into shock by doing the following…

  1. Isolate body substances by wearing protective gear such as latex gloves, safety glasses and face masks if possible
  2. Control any external bleeding
  3. Splint any bone injuries (see image below)
  4. Cover the patient to prevent heat loss
  5. Do what you can to keep the patient calm and comfortable while in transit
John Baxter – ©2007

The bottom line is if you suspect that internal bleeding is present, get to the hospital asap!

Conclusion:

The best thing you can do if you or a loved one is injured by gunfire is to try and keep your cool and avoid panic. If you panic, you will lose your ability to make split second decisions that are crucial for survival. You or your patient will also become more susceptible to lapsing into shock. Keep a clear head and remember your training.

Other References

  1. Prehospital Emergency Care”, Mistovich, Hafen, Karren, Werman, 2000 Prentice-Hall
  2. http://www.tracheostomy.com/resources/surgery/emergency.htm
  3. http://dirttime.com/?p=1035
  4. http://www.enotes.com/nursing-encyclopedia/tracheotomy
  5. http://www.armystudyguide.com/content/powerpoint/First_Aid_Presentations/triage-2.shtml
First Aid: Gunshot Wounds
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