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Discussion guide to Airways

Anytime we talk about austere medicine, naturally airways come up, and for a variety of reasons. Just to catch up our audience we are going to cover a few basics, so everyone is on the same sheet of music. In this article we wont cover how and when to use a particular airway, but we rather discuss the intended use to hopefully clarify what item does what.

Anytime we talk about austere medicine, naturally airways come up, and for a variety of reasons. Just to catch up our audience we are going to cover a few basics, so everyone is on the same sheet of music. In this article we wont cover how and when to use a particular airway, but we rather discuss the intended use to hopefully clarify what item does what.

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Positional Airways. These are free, weigh nothing and often overlooked for sexier, more invasive techniques. A positional airway is exactly what it sounds like, position the patients airway or body in a way that keeps the tongue off the back of the throat, or prevents them from inhaling vomit. i.e. The sniffing position, or roll you patient onto their side AKA the "Frat Boy" or recovery position.

2000px-Recovery_position_svg

Adjunct airways. Adjunct airways are temporary airways, that we put in place just to buy us a little time until we can do something a little more definitive. Although in many cases they are all that is needed or ever get used, they fall into the adjunct category simply because better airways are available to skilled providers.

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NPAs or nasal pharyngeal airways. The correct term is NPA but its ok if you call it a nasal trumpet. An NPA is designed to go thru the nasal passage and sit just behind the tongue and keep your patients airway open, essentially keep them from snoring. In order for these to work they have to be sized correctly for the patient before placement. Make sure you keep a variety of sizes handy, I see in training people who just go thru the motions of sizing them up..... These are uncomfortable for the patient but should avoid the gag reflex.

NPA

OPAs or Oral Pharyngeal airways. The correct term is OPA but if you want to call them a J-Tube that's fine as well. OPAs are large, smooth J shaped pipes are bridges that go thru the mouth and lift the tongue off the back of the throat. This will stimulate a gag reflex and they also fall out a easier than an NPA. Its for that reason NPAs tend to be the go to adjunct airway in the field. OPAs will pass more air in most cases, so EMS folks tend to prefer the OPA because it fits in a little better with other treatments they may do later as a provider. [gallery size="medium" link="none" orderby="rand" ids="2543,2542,2544"] Supraglottic Airways (Above the glottis AKA the air flap). I tend to categorize Supraglottic airways between an adjunct and a definitive airway like intubation or crics (we will explain). These airways are designed to go "Blindly" into the back of the throat and isolate the OPENING of the trachea, by either blocking off the esophagus, as in the case of the King Lt. or by chance actually landing in the trachea proper by chance as in the case of a Combitube which does both depending on where it lands.

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Supraglottic airways are procedurally easier than crics and intubation, but are still not considered definitve by most because they do NOT isolate the trachea. The right Supraglottic airway works well enough for anesthesia so they have the chops to save lives, but tend to be priced out the everyday persons IFAK. I like the KING LT by North American Rescue, its as close to Infantry proof as you can get while giving you operating room level performance. [gallery ids="2545,2546,2547" orderby="rand"] Definitive Airways. The goal of most providers is to isolate the trachea, this increases the effectiveness of any treatments they provide and reduces the risk of vomit or any other nasty's getting into the airway. If you ever get to watch an ER run a "mega code", you will notice a sigh of relief once the patient is "tubed" Surgical Airways. This is the first of two definitive airways we will discuss in this article. I've placed these just above the supraglottics, but frankly they are a teachable skill to the laymen provider. I've taught many an operator how to cric, and they have performed the procedure well. The only surgical airway we are concerned about in the field is the CricoThyroidotomy, or "Cric". With out getting into specifics you go in thru a small incision at the base of the Adams apple and slide a tube INTO the trachea. the tube should have an inflatable cuff on the end, so that when you inflate the cuff, gas must pass in and out the tube alone, and fluids cant get into the lungs. This technique bypasses the gag reflex altogether and is a great option for providers dealing with a potentially ugly airway combined with a head injury or disembowelment. This procedure is generally considered safe, im a fan of teaching it to dedicated responders but ill leave that discussion to people with letters behind their name. [gallery size="medium" ids="2548,2549"] Intubation. The gold standard for airways. Using a specialized scope and a properly sized cuffed tube, the provider slides a ET (Endotracheal) Tube directly into the trachea, and when they inflate the cuff they isolate the trachea the same as the cric we mentioned before. This requires a great amount of technique and experience, even seasoned paramedics dread having to do this in the field. A lot can go wrong and we certainly wouldn't recommend this to a laymen. Its good to know about this procedure even if you cant "tube" someone yourself. Ultimately this is where you patient is going if his level of consciousness allows it. This skill is generally for paramedic level providers and above and for good reason. It is entirely possible to use a modified version of this procedure and go thru the nose, but again it requires some skill and clinical hours to learn. [gallery columns="4" ids="2550,2551,2552,2553" orderby="rand"] Certainly there are a myriad of factors that will guide your decision on what to use and when, but that's not for this article. Consider:

  • Pediatrics
  • Individual anatomy
  • Spinal Injuries
  • Head injuries
  • Mass casualties scenarios

In the CAG tier 1 Med Kit we have a variety of positional airways and an NPA. Keep in mind the key to good airway management is a rock solid assessment. Here at Crisis Application Group we teach MARCH (The science is in the sequence) using what ever airway exam your competent in. and make sure to slow down for at least 5 seconds when look listen and feel. Of course if you have any questions hit us up on Facebook and as always thank you. [caption id="attachment_2314" align="aligncenter" width="654"]cagnet GREEN BERET MODERATED FORUM[/caption]

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Knock-off medical supplies: Is saving your wallet worth risking your life? 

This warning fully understands that many who seek self sufficiency are not made of money and may be on a fixed income.
It's always nice to get a deal on something by finding it online for cheaper, but when does the expression "You get what you pay for" come into play? When does quality become priority over price?  bogusCAT Medical Supplies should be that line in the sand.

In  CATS eat RATS: Tourniquet Comparison Article we addressed the difference between tried and true and unproven medical interventions, but now we're talking Knock-Offs and copy cats from trying to save a dime by going through unreliable vendors. Some may justify buying a cheaper tourniquet on non-reputable dealers because the differences aren't obvious to the untrained eye. Would you do that on medical supplies, such as heart or cancer meds?

I've seen many post pictures of their medical gear and I've caught fakes, knockoffs and at a minimum outdated gear. For instance, China has a terrible problem with infringing upon patents and not caring about which products they make look-alike. While it can often be harmless stuff such as clothing, there is simply no cheap way to go about quality medical supplies. If there is one thing to not be frugal about, I'd recommend it to be what you have to use on the worst day(s) of your life.

I've noticed no explanation needed for people to drop hundreds and hundreds of dollars into weapon accessories, just to turn around and relentlessly search Ebay or auction sites for used or knock off medical supplies. While I'm not denying the effectiveness of firearms and self defense, I will rebut with frequency of medical emergencies. How many times in your life have you needed to use your firearm in relation to times you've needed medical intervention? Nobody is immune to this, and you can't always trust "How to spot a fake" guides. Some are nearly identical and it is a fact that even the U.S. Military has bought batches of fake CAT tourniquets that have made their way into the battlefield, where they have failed when needed most. They are frequently used by "Military Simulation" (MILSIM) / Airsoft Operators to match their Plate Carriers to what the SOF uses without the cost. Their game is not life or death, but ours is.

The Boston Bombing is a testament to the proof of tourniquets in civilian, especially mass casualty incidents.

The Boston Bombing and Las Vegas Concert Shooting are a testament to the proof of tourniquets in civilian, especially mass casualty incidents.You may get lucky when you roll the dice, but I'll stack the odds in my favor and go into a situation with superior training and equipment. Use a reputable dealer to negate the risks associated with subpar products that you, your loved ones and your patients will need in the most common factor of emergencies: Medical Injuries and Illness.

References: CAT Knock-Off - http://www.scribd.com/doc/31121665/Combat-Application-Tourniquet-GEN-III-vs-E-CAT

 

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Standards: The tourniquet discussion

In the medical world, every lifesaving item you select to go into your aid bag is a critical piece of gear and should be viewed as a NO FAIL item, after all lives are actually at stake. When introducing a new medical product into the market, a professional should have the research and data readily available to back up their claims for said product. The basis of this article is about standards and maybe highlight some of the gimmicks that have been floated around to make a quick buck. Medical standards are critical with tourniquets (TQ) and their effectiveness because of the competitive history between military and civilian trauma models. As a former Special Missions medic who served as a voting member of the Committee on Tactical Combat Casualty Care (CoTCCC), the subject of tourniquets is very near and dear to me. Standards are essential and this article will discuss what the standard isn't and can’t be, what the standard looks like, how standards are achieved, followed by an example of what to look for when making tough decisions with your limited budget.

Full disclosure: We sell the Combat Application Tourniquet (CAT)

What the Standard Isn't

When shopping for gear, we often look to industry leaders as they have the credibility and experience to make recommendations for the inexperienced or new. But how is that credibility achieved? It’s the proven history of having done the hard work up front and having the documentation to show for it. If the only selection criteria someone has is how cool or "operator" a guy is there's going to be mistakes, and the medical world is no different. Consumers make the obvious assumption that due diligence has been made by the professionals in question. This isn't always the case, so its important to do some homework. Pulse oximetry is nowhere near the performance standard for a TQ. There are heart patients with no Pulse ox readings in some limbs....no tourniquets!

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Marketing IS NOT data. "Cool guy Johnny" used "product XYZ" is NOT data. It validates their experience but offers no quantifiable performance metric. Just because an operator designs and uses it doesn't mean it works, or will work for you. Where is the data collection, the peer reviewed studies, and the study comparisons? Simply put, “Tacticool” is not a standard. Often times, operators are only using a particular device, because this research was ALREADY conducted... When introducing a new device, just saying a Green Beret, Ranger or Navy SEAL used it isn't enough, nor should it be because the lives of our family friends and peers are on the line.

The fact is, a good medic can make bad gear work in a pinch!

But that level of anecdotal evidence shouldn't be confused with a product that will perform at the lowest common denominator.

What the Standard Looks Like

Larry Vickers of Vickers (Corrected from Viking) Tactical routinely presents, in an educational format, the quality of his content and validates what he teaches and why his product concepts work. He provides quantifiable data and demonstrations that support his methodology. Although his tactical experience is relevant, Mr. Vickers has created an virtual encyclopedia of content and data for his approach to tactical shooting and product development. He puts in the work and validates it without relying on “Tacticool” for credibility. He is “Tacticool” because he IS credible.

C.A.G. using Ultrasound with a CAT TQ

C.A.G. using Ultrasound with a CAT TQ

For a tourniquet, the accepted standard for performance is a Doppler study and in some cases, the ultrasound. It’s the only way we can ensure that the device has achieved total arterial occlusion, also known as stopping the blood flow. This test needs to be performed on a human thigh, due to the large amounts of tissue and pressure required to achieve end state. Basically, we need to see if a tourniquet on the upper thigh is strong enough to cut off blood flow all the way down in the foot. Arms are, generally speaking, easy to do and shouldn't be the comparative standard for use in the field. A tourniquet must work on both the legs and arms if it’s going to make it into an aid bag. There are a few other variables we also need to consider such as TQ width, ease of application and design but none of those mean anything if at the end of the day the TQ doesn't stop a major femoral bleed.

 

There is no question that a skilled provider can create an improvised TQ that meets all of these criteria and will perform when the moment of truth has arrived, but the conventional homemade TQ doesn't offer the market a PREDICTABLE standard in which to train, compare, plan and gather data. Manufactured TQs provide standardization and the ability to teach down to the lowest common denominator so that critical life savings skills can be decentralized into the hands of untrained providers.

Dr. Zeitlow reviewed the prehospital use of tourniquets (CAT Tourniquets used on 73 patients with 98% success) and Combat Gauze (used on 52 patients with a 95% success rate) in the Trauma Service at the Mayo Clinic. He added that "improvised tourniquets were uniformly unsuccessful." Dr. Zeitlow also noted that the Mayo protocol calls for Combat Gauze to be used only after failure of standard gauze. There are 2 CAT tourniquets and 2 Combat Gauzes on each prehospital vehicle or aircraft. -CoTCCC minutes 2014-

When building up to human studies you often see a lot of testing done with non-human models, for example live tissue and even mannequin or cadaver tests. Again, still not the gold standard even though it seems they are validating the product. This is important to understand because there has been a release of various test data comparing the Rapid Application Tourniquet System (RATs) TQ against the CAT TQ on a mannequin. While the findings are indeed in favor of the RATs, this data in no way undermines the value and performance of the CAT nor does it provide gold standard test results for the performance of the RATs.

The CoTCCCs Role in Todays Accepted Standards

It needs to be said that few groups of people have done more to save the lives of American Service members than the CoTCCC. They have a well-documented, battle proven track record of medical excellence. The CoTCCC are directly responsible for the current level of professional respect the military and special operations currently enjoys in the medical community nationwide, better yet, GLOBALLY. In the last few days I've read a lot of attacks on the CoTCCC in favor of fads, and it reflects poorly on the veteran community as a whole.

tccclogoMost active duty service members aren't aware of the CoTCCC because they have only been exposed to the intellectual product that they have been provided, loosely called TCCC. For active duty service members TCCC and CoTCCC are indistinguishable because it’s only in the civilian market where there is a new difference in the meaning. I’m not going to get into who did what and for what trademark, just know that if you have to play "six degrees of separation" to substantiate your TCCC claim, it’s misleading. My personal synopsis of the labeling issue is that the product was marketed and released before it was fully tested. In most cases that's ok because sales feedback is critical, but not in the medical world. A medical device will be in court and on trial the first time it fails. This has a huge potential to damage the credibility of the military medical model. It’s not a popularity contest, it is life and death so standards must be achieved and then maintained.

The RATs TQ displays the big red label associated with TCCC. This is misleading but I don't entirely put the blame on the RATs team, rather the company that markets the label. I know what it takes to get a medical device up and running and, thanks to regulation, it’s nearly impossible. The temptation to cut corners is too great to put the blame entirely on the makers of the RATs. Competing in a market dominated by the FDA is a challenge to all medicine and not just veteran owned companies.

Combat Gauze at shop CAG!

Whether it works or not is irrelevant to the fact that professional credibility has been entirely undermined by this marketing tactic. Moving forward, how are we to accept the validity of any research done in support of the RATs? A veteran owned business is not removed from the challenges of competing in a free market, and that means creating content and products that withstand scrutiny and criticism, beyond the standards of a civilian company. The established civilian market doesn't want to compete with us, they want us to falter. We have the experience to back up our ideas so veterans don't have to dabble in conjecture. There is an entire community of civilians looking to undercut the military medical model, especially in trauma, and its gimmicks like this that will feed their machine. Credibility is king. I want to be clear, I'm not shooting down the efficacy of the RATs TQ, but I see nothing that demonstrates proven performance. At first glance it appears to be a glorified rehash of the old surgical tubing and it looks like a lot of other designs that have come and gone in the last few years. I’d like to see the testing, I'd like to see results. If it turns out to be the next big thing then great, good for them. At the end of the day I wish them luck, but it looks like the cart is ahead of the horse. What Should You Be Looking For? That depends on what kind of market you're in. The war has been going on for 15 years, so it’s not that there isn't room for innovation but there isn't any need to take chances either. The data is out there to substantiate the extra dollars on a limited personal budget. The question is how bad do you want to save $15?  As I've mentioned from the onset of this article, we sell the CAT tourniquet and for good reason. I have personally used them so I'm happy to endorse them, but the CAT has a long standing, well documented history of saving lives. As recently as last year, the Mayo clinic is reporting upwards of a 98% success rate for properly applied CAT TQs in a pre hospital setting. Ill accept that standard for my family.

Combat Application Tourniquet at shop CAG

It is one of the industry dominating products because the data is out there to validate the few extra dollars it costs to buy one. Take a look and see, then ask yourself, does your tourniquet have any real results behind it? The CAT does and we've provided it below.

Conclusion

Medicine is an established industry with proven practices and standards that have been set for years because they have the proof that this approach works. Few markets have the same level of scrutiny as the medical and medical malpractice industry. Even Special Operations follows and acknowledges this fact, and it’s this approach to research and development that has established the SOF community as a credible research and development institution. We have to be careful as a community not to overlook quality standards in favor of the cool factor. Our company, Crisis Application Group Inc. (CAG) won’t be testing the RATS TQ. At the end of the day it’s the responsibility of the manufacturer to prove the validity of their product, not the job of competitors to disprove it. Our initial impression of the RATs TQ is so what, show me the data. We won’t be going down the "rabbit hole" of will it work or why it works, or doesn't. That's not to say it won't, it’s just that we aren't buying into the “Tacticool” marketing. Maybe one day the RATs will be ready for the big leagues, but so far it’s not and there's a lot of work ahead of them. CAG will stick to proven methodology, technology, and personal experiences.

 

Open source data: Combat Application Tourniquet cotccc-meeting-minutes-1402-final 030. CAT_Single-Routing_ 024. Final_tourniquet_working_group_minutes_march_2010 Chpt 8-Pg 91 023.1 TK CALL AAR_Jul-09 rebuttal to Johnson 026. The Military Emergency Tourniquet Program's lessons Learned with Devices and Designs - 2011 027. Tourniquets - 2011 029. Re-Evaluating the Field Tourniquet for the Canadian Forces 032. Israeli NSW Feedback_to _the_Field_(FT2F) #11 FT2F #12 - TQ Use in OEF OIF and OND - 16Jul12 022. Battle Casualty Survival with Emergency Tourniquet Use to Stop Bleeding - 2009

General TQ studies (Good reading) 009. Surgical Tourniquet Technology Adapted for Military and Prehospital Use - 2004 010. Laboratory Evaluation of Battlefield Tourniquets in Human Volunteers - 2005

 

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Austere management of Lower Back Pain (LBP)

lower-back-pain-&-cramps-in-early-pregnancy-left-blade-under-shoulder-34397

Austere management of Lower Back Pain:

 
    Lower Back Pain can be difficult to treat, even with the luxuries of modern medicine. In an austere environment, proper diagnosis and treatment can prevent further injury and start the slow process back to recovery so you can get one of your fellow Emergency Action Members back on their feet. This is a quick little introduction that barely scrapes the surface, and is not to be taken as gospel. Acute Lower Back Pain (LBP) has many causes, one of the most common is from improper form while lifting an object. I see it in day to day life from Deadlifting when form gets sloppy as higher weight is attempted while the athlete is tired.  It does not need to be heavy weight at all as I've also had patients pick up a very light object  at the wrong angle and were in a great deal of pain. This is why good form is important.
 
LowerBackPickup
 
 
     Back Pain, unfortunately, is not always an easy fix and definitely not a quick fix. Some have more chronic issues from herniations, disc degeneration, spondylosis/sponylolisthesis, and more that are much more difficult to fix. Others are caused over time from weak hip flexors, abductors or other muscular imbalances. It can even be caused from lots of high impact, especially if you have the wrong footwear or a Bug Out Bag on your back. These can all take us out of the fight, if at least for awhile.
 
  Before I get into treatments, I'm going to address the patient. With musculoskeletal issues, there is no magic pill that makes it go away and there is a lot of responsibility on the patients part. In my experience, I see many patients who do one of two things:
 
 
A.)   Fight through it and exacerbate the injury.
 
or
 
 
B.)   Baby it too much and it gets locked up and tight.
 
 
 
  Pushing through the pain because of your ego does not give it a chance to heal and babying it does not build it back up to help it heal properly. The correct answer is a happy medium, or as I like to call "Active Rest." This means resting at first, but not taking it too easy. Walking around if tolerated, stretching and foam rolling. This will help the healing process along. From there, progressively move in the right direction. It does not stop there, as there are many things you can do for a Lower Back Injury.

Treatment options to consider:

  • How to warm up and apply a heat compress in your situation.  (Heating up a towel)
  • Which medications, if any, to stockpile.  ( Muscle relaxers or pain management )
  • Herbal Remedies that work for you or patient. ( Some are a hit and a miss. )
  • Stretching, Foam Rolling, Massage ( work to regain full Range of Motion )
  • Physical Exercises to rebuild and strengthen core and supporting structures

It won't be easy, it won't be overnight, and you may not get back to perfect, but I guarantee you that failure to take care of yourself will only make it worse. Once an injury happens the first time, the second time can be twice as easy. I would recommend for anyone with LBP, as well as the Medic of an Emergency Action Group or other [caption id="attachment_1442" align="alignright" width="235"]( Just a few examples of some of the back exercises a physical therapist or other medical provider may show you) ( Just a few examples of some of the back exercises )[/caption] prepper group to have multiple reference books/guides/pamphlets. This includes finding out what pre-existing conditions/injuries you have in your group.If you prep food and water to prepare for eating or drinking, you should prepare your body for the rigorous labor of a survival situation or even the daily life of self sufficiency. Before an Austere situation, Physical Therapy can do much more for an injury than self care. Physical therapy regiments done consistently and properly can hopefully alleviate pain and have you moving in the right direction, but at a minimum prevent your LBP from getting worse. One of the books I recommend is the Treat Your Own Back book by "Robin Mackenzie." It doesn't end there, You'll want other books for the myriad of other musculoskeletal problems you may encounter, or that already exist in your circle. Finally, if you can remember one thing from this article ( Print it out and share it), Here's a couple red flags during a collapse to immediately seek higher medical care:

  1.  The patient complains of "saddle paresthesia" or numbness/tingling where a saddle would touch their legs if they were on a horse. (Makes it easy to remember)
  2. The Patient complains they have lost bowel/bladder control. This can be inability to hold it in and extend to unable to void bowels or bladder as well.

End note: I would like to ask you to comment with which methods of treatment, especially natural remedies have you used to manage yours or others? (There is no right or wrong answer, as different strokes works for different folks. )
 

 
 
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Every Day Carry (EDC) Tourniquets: What you may need if you have to draw your firearm

"Medical and trauma emergencies are the most likely crisis that you and your family will face in any emergency. If we look at the all the recent catastrophes faced by our great nation one thing stands out as the most experienced event; TRAUMA. It doesn't matter if it’s a chainsaw accident, tornado or a gunshot wound. Life happens and you need to have the right gear. "

  A firearm is the first object that comes to mind when an EDC or "Every Day Carry" list is mentioned. While I've seen card sized items and flashlights commonly added to most EDC's since then, there's a vital piece missing. We can agree that our EDC, especially our firearm, is to get through an emergency and protect ourselves and others...  But what if that does not go as planned?

Tourniquets came in useful for civilians during the Boston Bombing
The Boston Bombing: A testament of the effectiveness of tourniquets outside of the battlefield, as well.

In a situation where firearms or other weapons involved, the optimal end result is that the threat is taken down, good guy escapes unharmed. Unfortunately, you and I both know that with the nature of ballistics and a high adrenaline moment of stress, that this may not be the case.   Even if you have to remove your weapon from the holster, you or your loved one may be harmed in the process eliminating the threat, or you may even have shot a bystander in the process. Unless a paramedic is thirty feet away, that person may very well bleed out long before medical attention arrives. That's where your EDC Tourniquet comes along.

 

  Extremity (Arm or Leg) bleeding is the number one preventable cause of death in Trauma Situations, which means this situation is not to be taken lightly. A tourniquet applied properly may save a life in this instance. It's better to use one,  than hesitate and risk exsanguination or "bleeding out." The days of "Don't put it on or you'll lose that limb" are over, studies show that it will take 4-6 hours before permanent damage even begins.  Whether 911 is coming in 15 minutes or you are in an austere situation where help may be delayed or you may have to self-transport, none of that matters if they don't make it through these next few minutes. The decision is clear: Acting now or bleed out on the spot.   That's why I recommend a tourniquet being added to your EDC. Even if you don't carry a firearm daily, Medical injuries are far more likely in an emergency or austere environment than having to draw a firearm. That is why we're going to go over how to use a tourniquet and how to store them. We've already established types of tourniquets so you may make an educated purchase in another guide: Crisis Application Group: C.A.T's eat R.A.T's: Tourniquet Comparisons (CLICK HERE)

Self Aid is a critical skill
Self Aid is a critical skill  

If you can visualize a hole leaking water from a watering hose as the arterial bleeding and the faucet the hose is attached to as the victim's heart, you can know "Why" you're doing it:  the application of the tourniquet is basically you going farther up the hose (artery) to stop water (blood) from coming out. You may waste precious seconds with bandages and direct pressure hoping that fixes the wound. While those methods may be used to slow bleeding, you are going for arterial occlusion meaning the bright red bleeding stops.  "Twist, Twist, Twist the Windlass till the bright red bleeding stops." "Where do I put this thing?"   The CAT and SOFT-T only seem bulky but with a little folding you can make it's silhouette smaller. Personally, I carry at CAT tourniquet on me everywhere I go, and have at least 2 more in the car at all times. That's not even mentioning my medical supplies.

Buy the Combat Application Tourniquet (CAT)

A1   I recommend putting it on your belt, however this is not gospel and your imagination is the limit; You can use pockets, ankle holsters or truly conceal it under a shirt by looping it like a bandolier. With the belt method, you can loop the tourniquet through the belt as shown, using the velcro to your advantage.

  If you're worried about a tourniquet attracting attention on a belt, you can pull a shirt or jacket over it, just as with a pistol but with less chance and worry of imprinting. If you can't get it stable enough, try using thick rubber bands to tie it into the belt. If you still can't get it working or need a more durable container for extended wear and abuse, there are a variety of tourniquet holders that are commercially available that are smooth and keep it in good condition.

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CAT's eat RAT's: Tourniquet Comparisons

We have come a long way in trauma medicine since the days of "Use a tourniquet only as a last resort." We now know it can be on for hours before it even begin to damage the patient, and now tourniquets are often times your first intervention in tactical medicine

A Guide to avoid gimmicks in the world of Tactical and Austere Medicine:


Tourniquet+poster   We have come a long way in trauma medicine since the days of "Use a tourniquet only as a last resort." We now know it can be on for hours before it even begin to damage the patient, and now tourniquets are often times your first intervention in tactical medicine. It's now a rush to create the latest greatest equipment, especially tourniquets, to save lives both on the battlefield and here back home as referenced in their success in the Boston Bombing. Most often times these new medical innovations are not created by a scientist in some dark lab but the warriors who return from the battlefield and realize what we need. I applaud those who innovate in order to save lives and experienced Tactical Medics can make their own decisions about the newest medical interventions. Unfortunately, some products

come out seeming to be best thing since sliced bread and we here at Crisis Application Group are here to help you make an educated decision in what you choose to purchase because this purchase may be used to save somebody's life.  Every tourniquet has its Pro's and Con's that can and should be mitigated by rigorous training. When the human factor is eliminated as best it can through rigorous training, THEN we can talk about proper equipment.  It doesn't matter if you have the best tourniquet in the market if you can't use it properly.

 

 


R.A.T. Tourniquet:

CATSeatRATS   Cutting right to the chase: I'm not sold on the R.A.T. Tourniquet just yet. (Pictured:) it has "TCCC" approved on it, which is not the military's official "CoTCCC" which Crisis Application Group's CEO was formerly a member of. That could be misleading to many folks that think it has been approved for battlefield use. The RAT tourniquet is a flat bungee that works through wrapping the cord around the extremity to stop bleeding. While you could improvise many items to slow the bleeding, I expect total arterial occlusion from a commercial product. I have yet to see Doppler prove that it occluded arterial blood flow, studies on live tissue, or real CoTCCC approval. The RAT tourniquet page has video documenting it stopping the pulse through the use of a Pulse Oximeter, but that is not where the bar is set. I see the temptation with the lower cost and size, but in medicine you can't take the "idea" over proven effectiveness. In the game of saving a life, you may have to spend the extra dollar.

CAG Tier 1 Med Packs! Complete modular systems $99!

  There is also the argument about proper width, which is directly correlated to soft tissue damage and more importantly arterial occlusion. It states and is 1.5" when properly applied, which I will give them the benefit of the doubt. However, with items used in a high stress environment, you'll want a redundant product that is less likely to be messed up. For instance, if there is too much spacing between the wraps, or overlapping too much could require the Operator to re-do the intervention, releasing the tourniquets pressure. In addition, Some haFlatBungeeTourniquetve argued about the length of RAT tourniquet on a thigh, but after seeing a video demonstrates it's use on a 26" thigh properly, I have no complaints there.

  A large portion of the reviews say it's fast enough than taking an already 'looped' CAT from the foot of the patient and jostling it all the way up. I teach my TCCC students the option for a CAT to instead be applied through the friction adapter at the correct height of the limb. This requires less movement and going around the limb than the multiple loops of the RAT.   A tourniquet isn't just about putting one on, but keeping it on. I would like to see how it would hold up in casualty drags and carries, where rocks, debris and gear can cause a tourniquet to possible become loose and therefore less effective.   If we received one in the mail, we'd surely test it out further. Until then, we'll wait till we see more concrete proof.


SWAT-T Tourniquet:

[caption id="attachment_454" align="alignleft" width="372"]SWAT Tourniquet SWAT Tourniquet[/caption]

   This is the SWAT-Tourniquet. It's name is also how to use it: "Stretch, Wrap and Tuck." . It's an elastic wrap, I've used one in practice when I came across it. It was very strenuous to get working and after application to the legs and I put it on aggressive and tight. In addition, when finished wrapping, you have to find a place to tuck the tail into or it will unwrap itself, which was one of the largest issues I had. I would mention the pain, but that has no room in saving a life because "The Operator feels no pain (when doing medical interventions.)"  I would not recommend this product that is not CoTCCC approved and many units do not allow it. I wouldn't even use it as a pressure dressing to avoid compartment syndrome, and an ACE wrap is easier to see blood leaking through if your intervention fails.



Committee of TCCC (CoTCCC) Approved Tourniquets:

  The two tourniquets widely used in the the Special Operations community as well as experience in the staff here at C.A.G.,  but even more importantly have approval from the Committee on TCCC (CoTCCC) and Fort Sam Houston's Institute of Surgical Research are the Combat Application Tourniquet, version 3 -or- CAT3 and Special Operations Forces Tactical Tourniquet -or- SOFT-T/SOF-T. CATTrauma CAT-T   The CAT3 has been ol' faithful for quite some time. It does get a lot of hate, though, and as someone who has taught all different groups of people TCCC, I can see where it frustrates newcomers. Just like many other good pieces of equipment, a tourniquet is not a learn-once and done. The CAT3 needs some practice to get down smoothly, especially with the friction adapter. C.A.G. has a video you can watch to learn how to do it right and practice in order to stay under the goal time of 30 seconds.


** A CAT3 once used for training or any other purpose should not be used in trauma.

[youtube https://www.youtube.com/watch?v=BAF5LIxzOPo&w=420&h=315]

SOFT-T:   Special Operations Forces - Tourniquet is another tourniquet we recommend, but just as with the CAT, it will take practice to get it right. If you foresee you or others in your group having a hassle with the tightness of the screw or remembering it, the newest generation SOFT-T has a buckle that makes life easier. SOFT-TSOFT-TW (Wide version with Buckle instead of screw.) LEFT: SOFT-T RIGHT: Newer SOFT-TW Wide with Buckle in place of the screw.

 

 

 

Improvised Tourniquets: token1

  Improvised Tourniquets are as their name implies, using what you have available in an attempt to create a tourniquet effect. They are good to know how to make and have prepared for an austere or mass casualty incident where you do not have one, or do not have enough tourniquets. However, they do not work as well as commercially designed tourniquets, so prepare a few in case you run out and tuck it away in your intellectual equity toolbox. Our very own Crisis Application Group's Jay Paisley demonstrates just how simple it can be.

[youtube https://www.youtube.com/watch?v=0Q_ClfyM0Ls]



  What I hope you take away from this article is to be skeptical of new inventions proclaiming to be the next big thing, especially in the business of saving lives. I could go over every possible tourniquet on the market and write a book but I'm sure you got the point. When you come across one you're unsure about, do some research or even feel free to ask us about it. Inspect your tourniquets as you receive them, as some have cheap after-market knock offs made of cheaper, flimsy products or even an older generation of what's currently best. I also recommend you take your tourniquets out of the packaging and prepare them properly as fumbling around with that can cost a few extra seconds when the goal is preserving "fresh clean blood."

CAG Class: Intro to Austere Field Medicine, Conyers, GA!

  Once more, I applaud those out there creating these products to save lives on the battlefield, Law Enforcement Officers and even Civilians back home. I would love for a product that is smaller, faster and lighter than what we currently use, but more importantly I want one that can save more lives. It would be a safe bet to stand back and monitor a product you're interested in while it receives further testing and real world application to work out the kinks. Even the beloved Combat Gauze had criticism when it first came out and replaced Celox and Chitogauze awhile back, then in the new TCCC updates Celox/Chito are back in the game as alternate uses because they work intrinsic of the clotting cascade and may perform better for someone with poor clotting factors. It goes to show you that what you knew about medicine 6 months ago may not be correct, and what you knew a decade ago might not work as well as what is out today.   For now I recommend you stick with what you know and keep training. No matter which tourniquet you or your community purchase, buy at least two; One for training, one to keep when you need it. Mark/spray paint the training TQ to keep it separate and train on it often to stay fresh and keep your time under 30 seconds. The equipment doesn't live up to its full potential without proper, consistent training.   If you have any question on medical products, feel free to ask the medical subject matter experts here at Crisis Application Group about it. We have Special Operations, Special Forces, former CoTCCC members and other Medical Professionals that can give you a professional opinion. Trust the reviews of those who have used tourniquets on real life trauma casualties. [caption id="attachment_2" align="aligncenter" width="300"]Med training with Crisis Application Group Med training with Crisis Application Group[/caption]   Don't take our word for it, Check out these References and come to your own conclusion, or Google "TCCC" or "CoTCCC tourniquets" : JSOM TCCC References: https://www.jsomonline.org/TCCC.html TCCC PDF from U.S. Army Institute of Surgical Research updates, as of 02 June 2014: http://www.usaisr.amedd.army.mil/pdfs/TCCC_Guidelines_140602.pdf

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Where are the Doctors?

The Scary Reality of Casualty Evacuation to a higher level of care:

You see it on Medical Survival and S.H.T.F. blogs often; Preppers with little to no medical knowledge or experience asking how to cut holes in peoples necks to breathe for them, push antibiotics and intravenous fluids they don't know about, and throw in a chest tube by cutting a hole in their thoracic cavity. What if a wrong intervention is performed, or the right one but the wrong time and now the patient is worse? Would you want someone who has never done that

before to do it to you? In a life or death situation during a collapse, you may say yes as a last ditch effort. I'm not writing about not learning medical interventions as I love teaching medicine, and am one of the instructors for CAG. I'm going to explain why we should first consider alternate routes to give our patients the best chance that you could give them. Those routes are having a dedicated medical professional in the group as well as having a plan to get them to the nearest medical professional, whether that is a hospital, medical tent, volunteer center or a friendly Doc you've networked with down the road.

Acquiring a Dedicated Medical Professional:

I will start off this section by saying that I don't think medical people are capable of something you are not... as long as you have the training. keep-calm-i-m-almost-a-doctor-14That being said, finding a like minded medical provider could be difficult to get started, but infinitely worth the rewards. While having a full-blown Doctor or Special Forces Medic would be optimal, don't discount a Nurse, Paramedic, or even specialties like Dental Tech. A Medical Professional is not measured solely by their title but in my opinion by their passion and willingness to learn in order to remain competent.  Having a Doc will be able to help you in a situation where medical care is not available, but if they like to teach and you are eager to learn, they will more importantly cross-train the group so you can all be "mini-medics", much akin to the Tactical Combat Casualty Care (TCCC) program where Medics train ALL their non-medical platoon mates on what to do if they are not around or get hurt. An added bonus, is if the region you are in is unstable for long enough, the medical professional in your group could provide services to other locals for bartering, depending on their skill level. If it is a natural disaster, you could assist them in volunteering to help the affected area while learning along the way. Simply put, a dedicated Doc can provide more in-depth medical care by not just knowing "How To", but know "Why." You can be taught to treat a thousand wounds, but if you come across a wound you've never encountered, you won't be able to manage it unless you know how and why the anatomy, injury and intervention work. That is critical thinking.

"We simply can't find a Medical Provider"

Finding a "prepper" minded medical professional before-hand is an ongoing process... So why not become one? I recommend to everyone, preparedness minded or not, (especially if they have children) to take a First Aid/CPR class. Inexpensive, Quick, Simple and a good way to get your foot in the door. Not only will this let you know if medicine could be your forte or your kryptonite, but you can benefit more than just your group through what you have learned. m49140188_adult-first-aid-cpr-aed-classroom-550x324CPR/First Aid looks good on a resume before an emergency and could come up in day to day life. From that entry level you could go on to CNA, EMT,  or even volunteer with your local firefighters to work first hand with paramedics and those who handle wounded individuals often. From First Responders you can see how calm you should act in a medical situation and grow from that, while helping the community and making friends you could possibly turn into fellow Emergency Action Group members down the road.

I've treated the casualty to the best of my abilities...but 911 is simply not coming:

This is one of the most commonly neglected areas of most preppers medical plans. I see that they want to learn interventions far above their skill set because a Doctor is never coming... Wait, Come again? Where did all these Doctors go, did they get raptured away and disappear out of thin air? My point is: There will always be medical pro's. Just because finances, governments, resources, electricity and all else collapses, they won't disappear. There have been Doctors who operated without electricity since the olden days, that knowledge won't simply dissipate. Even in Katrina there were volunteer tents and triage centers when the Hospitals were overloaded or non-operational. It would have to be a very specific situation for there to be 0% chance for your patient to see the next echelon of care. The truth can be much more difficult, but the chaos of it can be managed by training: Medical Evacuation. Set a P.A.C.E. Plan (Primary, Alternate,Contingency, Emergency), Which is a fancy acronym meaning, "If Plan A Fails, Go to Plan B. If B Fails, Go to C, etc." You'll need to designate vehicles such as trucks, quads or even that tractor-trailer, to having to walk with a litter or SKEDCO dragging them behind you. Make sure to also ration and set aside fuel only to be used for hospital trips. Know where the nearest hospitals are, their type, your route to get there and every different way route with maps. The distance to your regions medical facilities matter so you can plan how long it takes with different methods to get there, xx minutes by car, xx minutes by ATV, and xx minutes by foot, for example. After that has been loosely calculated, you can road trip there with your group for a get together.If you were to have a member of your group get severely injured, how many of your group will escort him? How many will stay back to manage the property? How do you communicate if the towers are down?  Which vehicle stays, which goes? When do you expect them back if you don't have communications/radio? This possible logistics nightmare are all to be planned and walked through in a rehearsal. This is also where you make strip maps. You may know where the nearest hospital is and scoff at this paragraph but I ask you to ponder if you are the one that is injured and someone else is unfamiliar, a major road is closed or blocked by traffic, weather or debris, or you show up and the hospital is over run with a mass casualty. you may have a problem. Finally, knowing whether a hospital is a level 1 or 3, A Pediatric hospital or a volunteer clinic set up after a catastrophe can make sure your time is best utilized making sure your patient has the best chance you can get. This is a good habit to establish even if you have yet to join an Emergency Action Group, or moved to a new place. Additionally, How do you prove you can receive medical care, or can pay for it? You'll want to bring what you'll need to receive medical care, and more. If you can prove you have medical insurance and cash, that may work. If the grid and financial low is far beyond that leisure, make sure to bring what you will need to barter for this medical care. Gold, Food, or others measures. This can be set aside with the emergency fuel explicitly to be used only for the Casualties evacuation. In summary, You can see how a casualty can be a culmination of all a preppers skills and resources. You'll need to put your first aid skills to the test, stay calm to recognize if he needs more medical attention or not when you fall back on prior training during a moment of stress. You will execute a plan and three more back up plans with maps to get him or her on their way to someone who knows more medicine and account for setbacks. You may need to barter for care while you are there and use your communication set up to communicate back to your main location if you will have an extended stay. Keep learning austere/survival medicine, but also continue to account for ways you can provide them quality treatment if needed.  I hope you gathered multiple thinking points to discuss with your Emergency Action Group. Most of these can be planned and talked over for the low cost of printed paper. I 100% believe in what Austere Medicine is capable of. A handful of years ago I was a young medic in charge of the medical care for dozens of men for the first time on a remote outpost that was over 100 miles away from the nearest medical center. If the weather was too poor for a Blackhawk helicopter to get off the ground, or they were busy evacuating trauma casualties in another region to divert assets, I was all that there was. I learned that while controlling hemorrhage is the cool meat and potatoes of trauma, I needed to learn all aspects of medicine and dive into books to truly take care of my peers. I've managed broken bones, heart attacks and other medical emergencies at a time where if I made the wrong call and underestimated it, my patient would die, but if I called a MEDEVAC for someone who did not need it, I would be taking up the resources from the battlefield that really needed it. I've taught these lessons to U.S. Regular Army and Special Operations soldiers, to NATO soldiers and local Afghan Military and Police forces. I impart these lessons I learned to you as well, in hopes you can better the medical readiness of your EAG.

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How to do a trauma assessment for preppers (Graphic pics)

[caption id="attachment_200" align="alignright" width="300"]TCCC with CAG TCCC with CAG[/caption] Naturally before we begin it needs to be said: CALL 911. However since we are a page dedicated to prepping and crisis management, it stands to reason that in this venue there is no 911 or 911 isn't coming. Either way YOU need to act.... Why start with trauma? Trauma is universal to every major catastrophe that's hit the US since 1776. Of course we support learning how to shoot and the myriad of other skills required to stay ready, but trauma is statistically proven to be the most likely event you will 

encounter. Medical skills aren't sexy and tend to be put on the back burner in favor of more glamorous venues. A $2000 assault rifle ISNT going to stop bleeding or manage an airway is it? We get it, medical supplies are expensive and there is an army of "practitioners" who want to keep control over medicine, but that isn't going to cut it for a prepper. What medical program should look into? There are dozens of good programs out there and they all will be great additions to your tool box, but for a prepper nothing can hold a candle to Tactical Combat Casualty Care or TCCC. TCCC was intended to teach a NON TRAINED service members in the military basic life saving skills so you can rest assured your "allowed" to know this. It's also what all of the elite fighting forces use on their teams, this goes for Green Berets, SEALS, PJs, Rangers and so on. Its also designed for an austere venue where evacuation will be delayed or wont be coming at all, again another check in the prepper block. TCCC is backed with mountains of good data managed by Doctors and senior battlefield medics from across the DoD arsenal, this is a solid program for everyone to know. If we ignore the word combat and instead use the word austere, all of a sudden this program makes even more sense. Can you give blood? Can you manage a delicate airway? Can you offer definitive surgical repair? Can you manage a collapsed lung? If the answer is no, then your entire trauma strategy needs to change to reflect this reality. It doesn't matter if it's an enemy force denying you evac or an economic collapse, you're on your own... Where to begin? Start with the assessment. Look at it like the toolbox, and all of the treatments are the tools. Lets focus todays article on the toolbox. [caption id="attachment_340" align="alignleft" width="246"]TCCC trauma assessment TCCC trauma assessment[/caption] The TCCC trauma assessment is placed in order of statistic injury patterns that are ranked from the most lethal (short and long-term) to the least lethal. All the "science" you need to know is built into the sequence. When in doubt or you get overwhelmed or lost, just start the assessment sequence over and you'll do fine...



The sequence: Its easy, just remember MARCHE and treat as you go! [caption id="attachment_344" align="alignright" width="253"]Identify life threats Bleeding was controlled with a ratchet strap![/caption] M-Massive Bleeding. Here you are looking for pooling blood or fast bleeding you can see. We don't care if its bright red or not, those days are gone. You can die from losing venous blood also...If its NOT bleeding, skip it we will come back to it later. Ugly wounds are distracting but if they aren't losing blood (for now at least) they aren't a priority during your initial survey. We need to save as many blood cells and clotting factors as possible and most arteries bleed fast enough to kill you in minutes. This is where TCCC tends to deviate from traditional EMS medicine. EMS hinges on the nearby hospital to manage the internal medicine issues that come with bleeding out like losing the ability to clot and acidosis. Saving as much "clean" blood as possible early on the event will give your patient the best chance at long-term survival when evac may not be coming... Use tourniquets and pack wounds, this is for time so hurry up! [caption id="attachment_347" align="alignright" width="268"]Simple NPA Simple NPA[/caption] A-Airway. Concept: Is the air hole open? It doesn't do us any good to make a patient respire if there is no hole to pass air. While we prefer to teach a modified jaw thrust, we don't have a problem with the head tilt/chin lift technique from your CPR training days. In effect, we are temporarily opening their mouth and we asses "how open" it is by LISTENING for them to breathe. Remember, an airway blockage may not visible from a visual inspection, you still have to look listen and feel for air passage. During this initial survey, consider temporary adjuncts like a nasal trumpet (NPA) or a J-tube (OPA), we like using positional airways, aka the "drunk don't puke roll to the side" technique... [caption id="attachment_349" align="alignright" width="300"]NAR Chest seals NAR Chest seals[/caption] R-Respirations. This gets confusing with new providers. When we say respirations we intend to examine the mechanical structures that are required to breathe. Namely the chest. For TCCC purposes the chest is front to BACK, Adams apple to navel. Here you will apply seals as needed and check for any broken ribs that could haunt you down the road. IF a patient has a collapsed lung, you wont really notice any one thing jump out at you, things like deviated tracheas and one sided rise and fall of the chest are late and grave signs, don't wait for those... It will be a combined series of symptoms that we use to direct treatment in the field, but that's another lesson in itself. [caption id="attachment_351" align="alignright" width="300"]NAR saline lock NAR saline lock[/caption] C-Circulation. Here we will check pulses and other signs of perfusion/circulation, also we will wrap up any other "meat" wounds we skipped over during our initial blood sweep. IF you have the skills and feel the patient could benefit, now's the time to gain IV access, but that's a clinical decision based on your over all patient presentation and skill. Clean up all the boo boos we skipped and anything else we missed. H-Hypothermia/Head injury. Not much you can do for a head injury other that take note of their level of consciousness. This early on information and the progression of symptoms form this baseline will be invaluable to any Docs that see them later. [caption id="attachment_354" align="alignright" width="150"]Inexpensive options are out there Inexpensive options are out there[/caption] Always treat for hypothermia. In trauma we aren't as concerned about heart attacks rather its effect on clotting. If you have a patient with internal injuries we want clots, and cold patients don't clot! Even in the summer put a blanket on them. Dead people are cold to the touch, even in summer... Don't look at it like it's a weather issue, look at it like their internal over has been turned off... E-Evacuation. This is obviously your biggest issue as a prepper, or a commando. If we had this we wouldn't be having this discussion! In all seriousness evacuation may be only be delayed. Don't look at SHTF as the only event you need to worry about. Ice storms and tornadoes could delay your 911 evacuation and TCCC will carry the day until they get here. Most of the lives saved during the global war on terror are from non trained medical providers using simple adjuncts early on in the patients injury/evac cycle. What I mean is that untrained providers are proving this system works....Numbers don't lie. CAG also offers a no non sense trauma pack, inventoried by Special Forces medics, with high quality name brand tools to ensure that you have everything you need to your TCCC venue. Clearly labeling in modular cells its designed for the TCCC MARCHE complete with emergency blanket. In addition to the Tier 1 Med Pack we offer the TCCC training to go along with it!

CHECK OUT THE CAG TIER 1 MED PACK

Naturally we recommend taking a class on the subject. Please don't read something online and think you've check the block for medical training. Online programs are great for refresher and developing new strategy, but they simply don't replace the value of hands on skill training with experienced educators. We can recommend a few good online references if you're just interested in getting to know TCCC. As always thank you and follow us on Facebook@ Crisis Application Group! Helpful links:

  • http://www.naemt.org/education/TCCC/tccc.aspx
  • http://www.usaisr.amedd.army.mil/
  • http://www.havokjournal.com/national-security/inside-the-special-operations-combat-medic-course/
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