Since I was in my teens I’ve developed a disturbing talent for either being at the site of accidents as they take place, or arriving just seconds afterward.
I’ve witnessed motorcyclists “straighten out” a curve flipping multiple times, and another incident where a distracted biker run headlong into the the rear of a stopped work van. I’ve watched a college coed fly over the hood of my car when she ran out into traffic and was hit broadside by a little old lady a a large sedan. Car crashes? I’ve seen them from almost every angle, and have been involved in a few as well.
When I add them up, I’ve had to play the role of “first responder” until actual police, fire, or paramedics arrived at least a dozen times, with the most recent one coming just three weeks ago as a red SUV that was going well over the speed limit outside of my neighborhood hit another vehicle, and rolled four times in a crash I heard from a block away.
Fortunately, no one was in immediate danger of dying before an ambulance arrived in any of these instances. Considering my “talent,” however, I can’t count on always being that lucky. I want to be able to help, and not stand idly by without a clue if I could help save a life.
I received my first briefing on Tactical Combat Casualty Care (TCCC) during Gunsite Academy’s inaugural Defense Against Street Crimes (course review here), and decided that I wanted to take a class beyond basic first aid and CPR.
I wanted to take a trauma management class to learn the skills to keep people alive based on TCCC, and found just the introductory class I wanted in the 1-Day Basic Trauma Management class offered by Mike “Witch Doc” Voytko, a retired Special Forces Medic with SOB Tac Med.
Mike did 25 years in the Army, 14 of those as a 18D, or Special Forces Medic, widely regarded as some of the best field trauma management professionals in the world. Seven of those 14 years in the Green Berets Mike served in “special mission units.”
Put bluntly, Mike’s incredibly well-trained and highly experienced.
As tactical medicine typically takes place in the field and not in classroom or hospitals, we had our training outdoors on a farm near Sanford, North Carolina. We couldn’t ask for a more beautiful day or location for the class.
The class was built around Tactical Combat Casualty Care (TCCC) concepts, and focused on treating casualties according to the MARCH protocol.
MARCH stands for:
- Massive Hemorrhage
Mike made sure that we understood that as civilians who are not first responders that there needed to be an additional step as well to call for EMS, so our protocol is MARCH(E).
- Massive Hemorrhage
- Emergency call to 911
The very first thing we learned was the importance of Body Substance Isolation (BSI). There are lots of nasty blood-borne diseases in this world, and you don’t want to pick up something like Hepatitis C or HIV while trying to save someone else. Nitrile gloves (above) are therefore the very first things we grab for when approaching an apparent trauma victim, and if we have some sort of eye protection, slipping on glasses is recommended as well.
The first thing we learned to look for as part of the MARCH protocol after gloving up is to look for the presence of massive arterial bleeding. When you see it, you’ll know it. You must address these massive bleeds by closing off arteries in approximately 30 seconds, or your patient/victim simply isn’t going to make it. We say that graphically illustrated last week in the video we showed about why we don’t shoot people in the leg (or arm) as an “less lethal” alternative.
If those massive arterial bleeds are to the neck or in the torso there sadly isn’t anything anyone can do to save a victim at this level of care. The sad fact of the matter is that some wounds simply are beyond your control to fix. That caveat established, massive bleeding to the arms or legs is survivable if you have a tourniquet that can rapidly be applied.
There are all sorts of tourniquets on the market right now, and some of them show promise and may do the job… but I’m not read to trust them. There are only two tourniquets which have a long and proven record of hundreds of saves in combat theaters to earn the TCCC’s seal of approval, and those are the C-A-T or Combat Application Tourniquet from North American Rescue, and the SOFTT-W, or SOF Tactical Tourniquet-Wide from Tac Med Solutions.
Curiously, the small sampling of combat medics I’ve spoken with have a clear preference for the SOFTT-W, as they feel that the metal windlass is more sturdy, and they have noted (and as I have discovered first-hand in scenario training) that the C-A-T’s velcro sometimes touches itself and locks up before you want it to, costing precious seconds. Improperly applied C-A-Ts can also see the velcro pull free as you’re attempting to cinch it down. I choose to carry a SOFFT-W, but wouldn’t feel underequipped with a C-A-T.
TCCC guidelines are to place the tourniquet as high above the wound as possible on the limb, while Mike advocates placing the tourniquet 2-3 inches above the wound, especially if in wilderness conditions where immediate casualty evacuation is unlikely. Why the difference of opinion ? Take the class and find out.
What do you do if the arterial bleed isn’t to the torso or the extremities, but occur at the crease where the legs or arms joins the body? You pack the wound with gauze as tightly as possible and apply pressure until the bleeding stops.
[NOTE: A lot of people are under the impression that they don’t need to have a tourniquet, and that they’ll be able to make a field expedient tourniquet out of a shirt or a belt and a makeshift windlass. Some lives had been saved by such devices, but it doesn’t happen often. If the wound is severe and to a major artery, odds of you being able to build a working tourniquet from found objects and getting it applied to completely cut off the flow of blood before the victim bleeds out is very slim. Why chance it?]
Once you’ve checked for and have addressed any arterial bleeding, it’s important make sure that the vicim can get breath. In most instances, a conscious victim will quickly and immediately move to position where they can best breath.
What do you do? You let them.
Many times, that will mean they’ll end up leaning forward with their arms pulled in, shoulders rolled forward, hunched over. While I didn’t really think about it at the time, I’ve seen that behavior in both motorcycle crash victims I mentioned above, and the girl who went flying over my car after she ran into traffic.
Another option for conscious victims—and probably the best option for unconscious victims in most circumstances—is the recovery position demonstrated above. A sad, gross reality is that severely injured people often vomit, and if victims aren’t in a position to get that vomit expelled from their body, they may very choke to death on it. Well-meaning first responders have immobilized people on their backs worried about spinal injuries, only to kill patients who choked on the contents of their stomach, or died days or weeks later of aspiration pneumonia from inhaling it.
Mike isn’t a fan of the nasopharyngeal airway (NPA, or “nose hose”) that comes standard in many trauma med kits, and instead advocates positional breathing, or putting victims in the recovery position shows above. They recovery position is where the victim is on his side leaning forward, top leg pulled up to help create a space for the diaphragm to aid breathing, the lower arm under the head to provide support, the face angled away and down so any vomit more easily exits and doesn’t fill the lungs.
Again, allow victims to position themselves into a position where they can breath if at all possible, and in many instances, the recovery position may be your best option.
Once you have made sure that any massive bleeding (M) and airway (A) issues are addressed, the next part of the MARCH(E) protocol is to check the entire chest cavity from the navel (belly button) to the clavicle (collar bones). Specifically, you’re looking for penetrating wounds that may allow air to the chest cavity. If you find such a hole anywhere between the navel and clavicle, the best response it to patch it with an occlusive dressing that keeps air from being suck into the wound when the victim exhales.
If an occlusive dressing is not placed and the victim’s continues to have air sucked into the penetrating injury into the plural cavity surrounding the lungs, and they’re going to experience a tension pnuemothorax. The lung is not going to be able to re-inflate as much as more air is sucked into the chest cavity after each exhale, and eventually that lung will collapse. As more air gets sucked into the plural space, it can start affecting the other lung and even put pressure on the heart, causing a heart attack.
This is universally viewed as A Very Bad Thing, and can occur in just minutes.
Fortunately for us, there are many ready-made occlusive dressings on the markets called chest seals that are included in many trauma kits (or easily available for purchase to add to your kit), and they’re mostly very simply to use, being “peel and stick” in design.
Mike prefers the simple and proven non-vented HALO chest seal, which sticks to the body even if it is covered in sweat or blood thanks to using a sticky hydrogel to make the seal.
Basically, you slap the chest seal in place, listen for air leaks, and listen to the victim if he tells you that he tells you he can’t breath. If the patient is having trouble breathing, it may be time to “burp” the wound. If you want to learn how to do that, you’re going to want to take the class. Mike can show and explain it a heck of a lot better than I can tell it.
Keep in mind that when we’re dealing with penetrating wounds—particularly gunshot wounds—there may very well be an entrance wound and an exit wound to address. HALOs are great because you get two seals in each pack. Some other seals come one to a package, so you’ll want to buy them two at a time.
There’s also a variation of chest wounds, where the impaling object—say, a knife, shrapnel or piece of rebar in a construction accident—is sticking out of the chest. Mike can teach you how to seal those up using a combination of a chest seal with petroleum gauze as well.
That gets us through M, A, and R in the MARCH(E) protocol.
Now that we’ve checked the victim for massive bleeding (M) airway (A), and respiration/chest cavity (R) injuries, it’s time to address circulation, the more minor bleeding from veins near the surface. These are the lower volume, non-life-threatening veinous bleeds that ooze blood instead of spurt, and don’t require a tourniquet. These injuries are treated with pressure dressings, a bandage that includes a dressing to place over the wound, and a bandage to wrap around it and apply pressure. The two most popular on the market are the so-called Israeli bandage (created by an IDF medic), and the Olaes bandage.
It’s easier to simple show how these work with short videos than it is me try to explain them.
As you can see these are both very well thought out bandages, but the Olaes has the slight advantage of having extra gauze that can be pulled out from behind the dressing and packed into wounds, along with a piece of clear plastic that can help you create a makeshift occlusive dressing if you’re out of chest seals.
We learned to apply these to wounds to the extremities, torso, neck, and head.
Now that were have massive bleeding (M) airway (A), respiration/chest cavity (R), and circulation (C) in check, the next item on our MARCH(E) protocol is to keep the victim’s body temperature up. If the body isn’t warm, all sorts of bad things happen very rapidly that can kill the victim, even if you’ve done everything else.
Fortunately, preventing hypothermia is (theoretically) pretty simple: remove any wet clothing, and wrap the victim in a warm blanket. Wool blankets seem to provide the best bang for your proverbial buck, having the benefit of being rugged and economical, and they even help provide warmth when wet when other materials may fail.
Sadly, there’s not anything you can really do at this level to address head injuries (we’re talking injuries to the brain that can’t be treated with a pressure dressing) except to identify the signs of head trauma, such as blood or clear-to-white fluid (cerebral spinal fluid, or CSF) coming from the ears and nose. A simple way to check for non-obvious head injuries is to ask the victim the same few questions about every five minutes.
- What is your name?
- Do you know where you are?
- Do you know what day it is?
- Do you know what happened to you?
You can ask about their family and the names of family members and pets, etc. You’re simply looking to see if they start failing to be able to answer these questions. If they start failing these questions, or one or more their eyes stop reacting to light, then you’re probably dealing with a head injury, which is information you can relay to EMS when they arrive.
That’s MARCH, and that’s the the core protocol developed for combat medics. We’re not combat medics, though. We’re just good, prepared folks trying to keep people alive until the real professionals can get on-scene.
TCCC-based classes like SOB Tactical’s 1-Day Basic Trauma Management Class are great to help you provide aid until first responders can arrive, but the goal is always to get 911 called and get victims into the the hands of EMS so they can provide a higher level of care and transport the victim to a trauma center. If you’re not alone with the victim, getting someone else to make that 911 call to get EMS rolling to your location may be one of the very first things you do while getting your nitrile gloves on to treat the victim. If alone, you need to make the 911 call after running through your first MARCH protocol.
After we learned the MARCH(E) protocols and how to use the various equipment in our trauma kits, it was time for each student to take turns in a role-playing scenario. Each person would get a chance to both role-play as a victim, and then run through the MARCH(E) protocols on other students in the class as they played the roll of victim.
I stepped up to be the first victim, suffering from two very nasty wounds, an arterial bleed on my arm, and a chest impalement. I am apparently very clumsy, and tend to fall on pointy things.
It’s hard to see in the photo, but there’s a stick roughly the diameter of a chopstick poking out of my chest, and a wound spurting blood on my arm.
The student who had to hold me together correctly treated the spurting arterial bleed first, and the made the modifications necessary to get a chest seal to work around the impalement before wrapping me in a blanket.
From there, we had all sorts of injury scenarios to figure out, and to keep us on our toes, Mike wouldn’t give us a fully-equipped trauma kit. We’d have to use whatever we found in the kit and improvise.
We had everything from my impalement to simulated maulings by dogs (above) to slashed necks (below), to various gunshot wounds and stabbings.
In case you were wondering, it was my task to handle a hunting accident where the victim managed to take a .30/30 through the right side of his chest from front to back.
I had to apply chest seals both front and back, and then listen to make sure I didn’t need to “burp” the wounds to keep him alive for EMS. I was lucky in that Mike included chest seals in the trauma kit I was working from, and that didn’t have to improvise one out of the occlusive sheet in the Olaes bandage or the packaging of a bandage or dressing.
It was a fascinating class with a great group of students, and I would highly recommend this class or other TCCC-based training to you, even if you don’t happen to own firearms or be around guns.
I have no way of knowing if my “talent” for being around significant accidents will continue, but now that I have some solid training—trauma kits in my home and both vehicles and some basic medical gear incorporated into my everyday carry (EDC) gear—I know that I’m now in a much better position to help others and maybe even save a life, and that made this class very worthwhile.