Get a med kit if you don't already have one...

[RJ]

...I didn't mention high-or-die specifically...

I like this because it is about the only thing that my Lizard Brain is likely to remember in a situation like this.

I looked for my mini-compression bandages last night, didn't find em. Must look harder. Got my nitrile gloves, a SOFTT-W, and a clotting agent located though. Just need to package them up tonight and start carrying the freaking things. I'm making a pact with my self that I will be put as much emphasis on my IFAK being on me as I am on my gun being on me.

Damn this is a good thread.

[Kram]

I'm making a pact with my self that I will be put as much emphasis on my IFAK being on me as I am on my gun being on me.

Damn this is a good thread.

Same here. Just ordered a second Ryker Nylon AFAK. I now have an extra one to keep at home when off duty. No more excuses of going without basic medical gear.

[einherjarvalk]

I have a Blue Force Gear MTKN! in my backpack, an ESSTAC IFAK set up for belt use at outdoor ranges (indoor one I go to has Dark Angel Medical kits in every bay), and a modest med bag my dad gave me last Christmas that I supplemented with proper trauma supplies and a CAT Gen 7 velcroed to my car's trunk liner.

This thread is making me think a PHLSter PEW and Flatpack with SOF-TT might be next on my list.

As an aside, if you know someone who's just getting into the mindset of "I should have trauma kits ready," please make sure they're getting good training and are being educated on what makes for good med kits. I spotted these disasters in a Facebook targetted ad only for them to pop up again on Primary and Secondary getting the shellacking one would expect them to get, but based on the fact that these "Guess I'll Die" Starter Kits are sold out, I'm guessing there's a lot of average Janes and Joes out there who aren't educated enough to see these for what they are.

https://www.studentofthegungear.com/...s/medical-gear

[Darth_Uno]

High-or-die is a 99% solution that requires remembering only one thing. Limiting judgemental and conditional tasks is critical for lay rescuers with minimal training and experience. If the limb is bleeding and DP isn't working, shut it off. Other rescuers can reevaluate the work and make changes as indicated.

This was briefly discussed in the class I was in. The instructor said you always want to go as high as you can, then something along the lines of, "That's not always true, but that's all you need to know." Guys like me aren't pros, we just need to keep you alive until the pros show up.

[Nephrology]

For most instances, yes. I just had to retrain the entire squad after skills update from a kinda affiliated EMT-IC. If you are providing care to yourself or another during or immediately after a gunfight, win the fight, if possible. Get off the X while winning the fight if possible. If not, then get the patient off the X, and TQ high and tight, over clothing, unless not feasable (winter clothing, etc). Sweeps, Rakes, pressure and pack. For me and my guys, if they are only going to remember one method, I prefer it to be along the lines of TECC. That said, for non "tactical" patient care expose, 1.5-2 inches proximal to the wound, pack and pressure bandage while awaiting transport. I have a level one trauma center literally minutes away in my jurisdiction, (IIRC you are VERY familiar with the facility and people), and AFR's EMT-Ps are TQing everything high and tight... I have yet to see one make it to the OR..The ED staff get them off in the Trauma Bay as a general rule.

MSparks, you done good.

Just picking nits, my friend Nephrology, not slighting you, your training, or experience.

pat

For sure, no offense taken. You'll never ruffle my feathers with a countervailing opinion. I also generally don't make it my business to be on, off, or even within 5 miles of any particular "X" so I welcome the different perspective.

Depending on the injury it may not need to go to the OR - on my last shift repaired a bunch of real nice lacs from a lady who cut up her forearms real good with a box cutter. Could see tendon, bones, veins etc. No major arterial injury outside of a small radial bleeder we tied off with a figure 8. I finished the repair while she took a little haldol nap. Never went to the OR.

Big/complex arterial injuries will get rolled to the OR with the TQ in place. Femoral arterial injury springs immediately in mind.

I forget - are you in CO? Feel free to PM

High and tight is also currently advised.

Just depends on what organization you're asking.

I have a particular bias, obviously, so I will always defer to the American College of Surgeons/their Committee on Trauma. Guy who wrote the booklet I linked is a former attending at my institution, taught my most recent BCon recert.

I also am not typically exposed to incoming gunfire so I can understand how the simplicity of going high may be more applicable in other settings with which I have dramatically less experience.

It's also probably much more appropriate to err on the side of higher in the setting of fracture.

@nephrology needs no medical education from me, but for the benefit of those listening...

High-or-die is a 99% solution that requires remembering only one thing. Limiting judgemental and conditional tasks is critical for lay rescuers with minimal training and experience. If the limb is bleeding and DP isn't working, shut it off. Other rescuers can reevaluate the work and make changes as indicated.

Application proximal to the wound also works and can be a better plan. However, it requires the lay rescuer to consider distance and potential involvement of joints. Already in the last few posts we've seen two different distance measures that will be assessed visually in the heat of the moment. Application proximal to the wound may also involve combinations of less tissue, more bone, smaller circumference with resulting effects on control. As many lay rescuers will be using field expedient TQs, this matters more.

I have experimented with umpteen drill sets and recommendations for teaching TQs across diverse populations, and been astounded by the axles some get wrapped around. Easy-buttons rule, especially for lay rescuers and the minimally trained.

In my earlier post, I didn't mention high-or-die specifically but I touch on the decision making process and what the best way looks like for me and mine.

All valid points. Definitely never apply a TQ over a joint like a knee, elbow, wrist, or ankle. If the injury is at or close to a joint, go above the joint such that you are clear of bony prominences (shins are fine).

I will note that there are a couple slight anatomical advantages to going just above the wound vs. high on the arm/leg:

1. Arteries become increasingly superficial as you go proximal -> distal (torso -> fingers and toes), which makes it easier to achieve hemostasis (especially relevant with obese or anticoagulated patients)

2. Less of a priority, but the closer you go to the injury, the less healthy tissue you deprive of blood. Muscles and soft tissue can go 60+ minutes of ischemia (interruption of blood flow) without suffering permanent injury, so this isn't something to lose sleep over outside of austere environments

[TGS]

It's also probably much more appropriate to err on the side of higher in the setting of fracture.

...and especially with blast injuries, of which this qualifies. "Distracting injuries" and all that...….one of the takeaways from .mil TQ use is that a fatal error is applying the TQ distal to the bleed site. People often see this is course material and think, "Well that's fucking stupid"......usually having never seen a blast injury, and failing to realize that a smaller piece of shrapnel...barely noticeable...could hit the artery higher than the mangled end of the limb you are naturally attracted to.

This is made worse by poor detection techniques. Blood sweeps are fucking retarded, because it's super easy to miss a wound. I've passed my hands over pistol, 5.56, and 7.62x39 wounds on a warm patient pumping blood without being able to feel them. That experiential learning also applied to at least 1 exit wound, not just entrance wounds. The idea that exit wounds are always going to be bigger and gross is a myth.

When I teach B-Con, I make a point of not only "raking" as opposed to sweeps, but really digging in with your finger tips. GSWs tend to be very small, and even raking can miss it unless you're really going at it like a fucking honey badger.

This is why there's such a strong push in the LE/Mil community to just default to high and tight. It's super easy to miss a wound that will kill you, and according to CoTCCC that wrote the book on all of this, it's totally not worth risking someone's life over.

2. Less of a priority, but the closer you go to the injury, the less healthy tissue you deprive of blood. Muscles and soft tissue can go 60+ minutes of ischemia (interruption of blood flow) without suffering permanent injury, so this isn't something to lose sleep over outside of austere environments

Have there been any more recent studies on this? Last one I can remember is from 2006, following the application of 400+ TQs on 300+ limbs on 200+ patients, includes TQs in place for up to 8 hours. Less than 3% of the patients experienced any tissue damage, and of them all were temporary palsy and resolved within a week. No permanent tissue damage could be attributed to the TQs themselves. I think I added the reference to my B-Con slides incase anybody wants it.

_________________


Which, speaking of B-Con, I get a day off at home about once every 4-6 weeks right now, so I haven't been keeping up with teaching it. However, if anyone wants the class in NoVA I'd be happy to try and take annual leave to do it, provided you get me an HDMI-compatible projector and room big enough (and appropriate) enough to do the skills for 8 people with a wound simulator that spurts blood. I like to teach it as a 4 hour session to a small group instead of the common 1-2 hour/huge group format, and spend a lot of time on actual skills...in particular how to properly pack a wound. No charge, and you get to meet the man who Tom Jones once described on first sight as, "I thought you'd look like more of a douchebag." I like doing it, and could use the break from work regardless.

[TC215]

Same here. Just ordered a second Ryker Nylon AFAK. I now have an extra one to keep at home when off duty. No more excuses of going without basic medical gear.

I bought Ryker AFAK’s for all the guys in our narc unit a month or two ago. Everybody loves them and there are no complaints, which is almost unheard of when it comes to cops.

FWIW, we’re taught to TQ just above the injury, but I’m far from an expert. That’s just how our SWAT medics taught us.

[JDD]

...

This is made worse by poor detection techniques. Blood sweeps are fucking retarded, because it's super easy to miss a wound. I've passed my hands over pistol, 5.56, and 7.62x39 wounds on a warm patient pumping blood without being able to feel them. That experiential learning also applied to at least 1 exit wound, not just entrance wounds. The idea that exit wounds are always going to be bigger and gross is a myth.

When I teach B-Con, I make a point of not only "raking" as opposed to sweeps, but really digging in with your finger tips. GSWs tend to be very small, and even raking can miss it unless you're really going at it like a fucking honey badger.

_________________


Which, speaking of B-Con, I get a day off at home about once every 4-6 weeks right now, so I haven't been keeping up with teaching it. However, if anyone wants the class in NoVA I'd be happy to try and take annual leave to do it, provided you get me an HDMI-compatible projector and room big enough (and appropriate) enough to do the skills for 8 people with a wound simulator that spurts blood. I like to teach it as a 4 hour session to a small group instead of the common 1-2 hour/huge group format, and spend a lot of time on actual skills...in particular how to properly pack a wound. No charge, and you get to meet the man who Tom Jones once described on first sight as, "I thought you'd look like more of a douchebag." I like doing it, and could use the break from work regardless.

The high speed black operator nitrile gloves look cool, but I can't help but feel like they make blood sweeps that much harder. (assuming of course, that your gloved hands are not already covered in blood anyway from whatever the more obvious or messy injury you are dealing with.)

WRT raking: the most eye opening aspect of my medical training was just how hard it can be to find a small entry wound without basically mauling the bare flesh.

[ST911]

The high speed black operator nitrile gloves look cool, but I can't help but feel like they make blood sweeps that much harder.

Black gloves suck.
Black gloves suck.
Black gloves suck.

[UNM1136]

The high speed black operator nitrile gloves look cool, but I can't help but feel like they make blood sweeps that much harder. (assuming of course, that your gloved hands are not already covered in blood anyway from whatever the more obvious or messy injury you are dealing with.)

WRT raking: the most eye opening aspect of my medical training was just how hard it can be to find a small entry wound without basically mauling the bare flesh.

The patient gives up all expectation of dignity and modesty when they need savin. If they are conscious and don't feel violated when you finish raking, you are doing it wrong.

I was on the NAR website a couple of weeks ago, and saw their tan gloves...still only good for the first bleed, but I can imagine they are better in reduced lighting. I never got black gloves, only what I could boost from the hospital or off an ambulance, or out of the evidence supply locker. Didn"t we change our guns and armor from tactical black to tactical coyote a little over a decade ago?

I like self sweeps as part of the Post Engagement Sequence that ALERRT teaches. Sweep the sides of the neck, check for blood. Sweep the armpits, check for blood. Run your hands from each knee to your crotch, check for blood.

pat