Contact!

by Max Velocity

  I would advise that you don’t sacrifice suppression for speed. Don’t let the suppressive fire slack up or lose accuracy in order to be able to run faster over the ground. Go for momentum instead, where you build pressure on the enemy by accurate volume of suppressive fire and then begin to maneuver, preferably to a flank. Never underestimate the psychological effect of your maneuver on the enemy, particularly if you get to a flank. You may push them to withdraw without it getting to a close fight-through battle.

  So to answer the original question: if you cannot get fire superiority, then get better suppression by employing accurately targeted fire. Train and practice together to get your battle drills squared away as a team. Orchestrate your team using accurate suppressive fire and the terrain i.e. cover, in order to be able to maneuver on the enemy, gain the upper hand, and close with and destroy them.

  CHAPTER SIX

  CASUALTIES

  “When you're wounded and left on Afghanistan's plains,

  And the women come out to cut up what remains,

  Jest roll to your rifle and blow out your brains

  An' go to your Gawd like a soldier.”

  KIPLING

  Introduction

  No discussion about surviving in a hostile environment and using weapons to defend against lethal threats would be complete without a discussion on wounding and trauma care. This is a very detailed subject and this instruction will concentrate on actions at the point of wounding and an introduction to some basic techniques as used by both Combat Lifesavers and Combat Medics in the US Army.

  It is important to remember that both for civilian first responders and for lifesavers on the battlefield, there is an expectation that casualties will be evacuated promptly to definitive care, either at the local emergency room or at the combat hospital (CASH). Time to care is either the time for the first responder ambulance to retrieve the casualty to the hospital or for combat casualty evacuation to get the combat casualty to the CASH, which is hopefully less than one hour and no more than four; this will depend on the remoteness of the casualty and the availability of assets such as helicopters or vehicles to evacuate the casualty.

  In a post event situation, you probably will not have access to an emergency room. You may have access to trained medical professionals and you may have access to some supplies and equipment. Some injuries will require surgical intervention to save life and this may or may not be available. Secondary infection will kill casualties, just like in the old days, so you need to have access to antibiotics. You may end up bartering for medical care, if you can find a doctor or surgeon. You need to prepare yourself as thoroughly as possible with medical training, resources and supplies. What follows is a summary mainly about trauma care and does not substitute for training and professional knowledge.

  The U.S. Army trains soldiers as Combat Lifesavers (CLS) to a certain standard, which equates to providing battlefield first aid. Combat medics are trained on the civilian side as EMTs and on the military ‘Whisky’ side (from 68W –sixty-eight-whiskey - the MOS indictor) at a more detailed level to deal with primary care and battlefield trauma. What medics learn on the whisky side would be illegal for an EMT to do. EMTs are basic life support and often the role of an EMT comes down to being able to provide CPR and providing ‘oxygen and rapid transport’ to the emergency room. For a combat medic, for casualties ‘on the X’ only limited interventions are allowed, and even once ‘off the X’ but still in a tactical environment CPR is not considered appropriate on the battlefield.

  Some procedures that are appropriate in a civilian ambulance situation are not appropriate on the battlefield. Ambulance crews may give fluids to casualties on the way to the hospital, where blood is available. They can keep putting the fluids in and get definitive care once they arrive at the emergency room. In a battlefield situation, fluids are not given except in specific circumstances. In simple terms, when you go into true shock by losing circulating body fluids (i.e. blood) your blood pressure will drop. As your body responds to the injury and the loss of blood, it will draw blood into the vital organs at the core of the body, at the expense of the limbs.

  Thus, as blood pressure falls you begin to lose the distal pulses (i.e. in the wrist and foot), then closer and closer to the core until you have no pulses but the heart, and the heart will be the last to give out at the lowest blood pressure. In a combat situation, if you give too much fluid, there is a danger of ‘blowing the clot’ and effectively bleeding out while diluting the blood left in the body, reducing its ability to carry oxygen. Also, fluids frequently given such as Lactated Ringers are rapidly absorbed into tissue so over time they are not really effectively increasing the volume of the blood. Hence the giving of fluids in the ambulance, where in very simple terms you can keep putting it in until you reach the emergency room and blood/plasma products are available.

  The fluid given for a traumatic wounding on the battlefield is not lactated ringers or similar, but Hextend, which is a starch product. Over roughly an hour, 500cc of Hextend will draw fluids out of surrounding tissue and bulk up to around 800cc. Guidelines state that you can use a maximum of two 500cc bags, 30 minutes apart. The protocol is only to give fluids if there are no radial (or pedal) pulses, which are the pulses in the wrist or foot. The reason is that you want to bring the blood pressure up enough to restore distal circulation to the extremities but no more, because you don’t want to blow any clots or cause the casualty to bleed out. For other injuries such as dehydration other fluids are still given, but not for trauma.

  The fact is that a large number of combat injuries are not survivable. Sometimes this will be obvious and the casualty has no chance of survival. Other times, survival will depend on appropriate interventions followed by rapid evacuation and definitive surgical care. There is a difference between being able to keep someone alive at the point of wounding and continuing to keep them alive due to the presence or absence of available definitive care.

  Do what you can to initially prevent death and get them to someone who can help, or worst case read some books on battlefield surgery and do something yourself, even if it’s just cleaning, debriding and suturing wounds and providing antibiotics, hoping that internal injuries and bleeding are not too severe and will heal in time.

  Combat Medic protocols do mainly assume that body armor is worn, which will reduce the incidence of penetrating trauma sustained in combat to the torso and the damage and resulting internal bleeding. Historically, 90% of combat deaths occur before the casualty reaches the treatment facility. The three major, potentially survivable causes of death on the battlefield are: extremity hemorrhage exsanguination (severe bleeding), tension pneumothorax (oxygen shortage and low blood pressure due to a collapsed lung, a condition that may progress to cardiac arrest if untreated) and airway obstruction. Historically, the most frequent and preventable of these causes of death is extremity bleeding. Thus, think about it: wear body armor if you can. Most wounds to the extremities will cause death by bleeding out, and this is preventable.

  As with all things medical, in reality things can be very complicated and involve complications and reactions of individuals to treatment. Much more complicated than what is written here. The purpose of CLS training is to simplify diagnosis and treatment of certain injuries and conditions to allow procedures for certain interventions, in the hope of equipping CLS to save lives. It’s not the whole answer, and medical professionals could give you the detail and the lists of possible complications of any of these interventions. For a wider view of medical care, extending beyond combat trauma, read useful books about it, and if you have the time available get some medical training.

  Tactical Combat Casualty Care (TC3)

  Casualty actions and procedures are comprehensively covered under Army Tactical Combat Casualty Care (TC3) Procedures. A summary will be given here. The summary involves techniques that involve training; this will give you an idea, but you need to collect the right equipment and train to be able to do it. Wors
t case, most of the ‘Whisky’ training videos can be found online, so you can at least see what is required and prepare yourself.

  The three main preventable causes of death on the battlefield are: extremity bleeding, airway obstruction and ‘sucking chest wounds’ (pneumo or hemo-thorax, or combinations). Combat Lifesavers are trained and equipped to cope with these problems at a basic level. Casualties will need to be seen by the Team Medic and then rapidly evacuated for more complicated procedures. Some combat wounds are simply not survivable and will not respond to medical attention i.e. severe internal bleeding or visible brain matter etc.

  Unlike the normal ABC medical protocol that you will have heard about, the combat protocol for trauma situations is H-A-B-C, which puts hemorrhage before Airway, if it is indicated, but still includes circulation for less serious bleeds and IVs. The other big difference is tourniquets: tourniquets used to be considered a tool of last resort. Now they are considered a tool of first resort in a combat environment. The following article does not presume to attempt to give all the answers, but it is a basic summary.

  Combat lifesaver (CLS) training should be given a high priority to ensure that casualties who would have a chance of being saved at the point of wounding are given the immediate care that they require. Individual First Aid Kits (IFAK) should be maintained, stocked and carried as per your team SOP. The IFAK can be improved from how it would arrive as issued by the US Army and additional medical supplies should be placed in the pouch as per guidelines from the Team Medic. Additional tourniquets can be carried on the person as per agreed SOP, such as in the lower left ACU trouser pocket. The IFAK should be inspected prior to every mission as part of PCC/PCI procedures. The IFAK should be carried in standardized place on your gear and it will be the resource that the CLS will use to treat you when you are reached. CLS will not treat from their own IFAK. Suggestions for the IFAK:

   CAT Tourniquet x 2 (one carried in pants pocket).

   Needle decompression kit (pen case style).

   Occlusive dressing.

   Israeli pressure bandage.

   Kerlix or preferably:

   Combat Gauze (commercially available as Quick Clot brand)

   ACE bandage (for wrapping up Kerlix or combat gauze wound packing)

   Tape

  CLS should not expose themselves to danger in order to recover a casualty. It is the job of the tactical commander to make and execute a rapid plan, including gaining fire superiority, to recover any casualties if the tactical situation allows it. It may not. The situation may not allow immediate casualty extraction and treatment. Consideration can be given to ways of reaching and treating a casualty that minimize risk i.e. use of vehicles as mentioned later etc.

  Care Under Fire

  In this phase the casualty is ‘on the X’ at the point of wounding. This is the point of greatest danger for the CLS. An assessment should be made for signs of life (i.e. is the casualty obviously dead). Cover fire should be given and fire superiority achieved. The casualty should be told, if conscious, to either return fire, apply self-aid, crawl to cover or lay still (don’t tell them to “Play dead!”). Once it becomes possible to reach the casualty, the only treatment given in the care under fire phase, if required, is a hasty tourniquet ‘high and tight’ on a limb in order to prevent extremity bleeding. The casualty should be rapidly moved to cover (drag them). Be aware of crowding, secondary devices and ‘come-on’ type attacks.

  Tourniquet application: ‘high and tight’ means right up at the top of the leg or arm, right in the groin (inguinal) or armpit (axial) region. The tourniquet needs to be cinched down tight to stop the bleeding.

  When applying tourniquets, they need to be tight enough to stop the distal pulse i.e. the pulse in the foot or wrist, if the limb has not been traumatically amputated. You will not be able to check this pulse at this phase, so just get the tourniquet on tight and check the distal pulse as part of the next phase, tactical field care.

  Traumatic amputation: get the tourniquet on high and tight and tighten it until the bleeding stops. Note: in some circumstances there will be pulsating arterial bleeding and severe venous bleeding, but other times it is possible that there may be less bleeding initially as the body reacts in shock and ‘shuts down’ the extremities, but bleeding will resume when the body relaxes. So get that tourniquet on tight.

  Compartment Syndrome: you don’t want to be feeling sorry for the casualty and trying to cinch the tourniquet down ‘only just enough’. Tighten it to stop the distal pulse. If you don’t, the continuing small amount of blood circulation into the limb can cause compartment syndrome, which is a build-up of toxins: when the tourniquet is removed, these toxins flood into the body and can seriously harm the casualty.

  Tourniquets used to be considered a tool of last resort. Now they are considered a tool of first resort, and one can be on a limb for up to 6 hours without loss of that limb.

  For an improvised tourniquet, make sure the strap is no less than 2 inches wide, to prevent it cutting into the flesh of the limb.

  Tactical Field Care

  Once the casualty is no longer ‘on the X’, CLS can move into the Tactical Field Care phase. This may be happening behind cover, or as the convoy speeds away from the killing area, possibly at a rally point, or subsequently as the convoy speeds back to a safe haven. On the battlefield, CPR is not appropriate: a casualty needs to have a pulse and be breathing for further treatment to occur (CPR may be appropriate, for example, if the injuries occur at a safe location, from some sort of accident). This is where the CLS conducts the assessment of the casualty and treats the wounds as best as possible according to the H-ABC mnemonic:

  Hemorrhage: During the Tactical Field care phase, any serious extremity bleeding (arterial or serious venous) on a limb, including traumatic amputation, is treated with a tourniquet 2-3 inches above the wound. Axial (armpit), inguinal (groin) and neck wounds are treated by packing with Kerlix or combat gauze and wrapping up with ACE bandage.

  Once you have dragged the casualty to cover, you will conduct a blood sweep of the neck, axial region, arms, inguinal region and legs. This can be done as a pat down, a ‘feel’ or ‘claw’, or simply ripping your hands down the limbs. Debate exists as to the best method. Conduct the blood sweep and look at your hands at each stage to see if you have found blood. Once a wound is found, check for exit wounds. Ignore minor bleeds at this stage: you are concerned about pulsating arterial bleeds and any kind of serious bleed where you can see the blood rapidly running out of the body.

  Beware of deliberate tourniquet application to the lower limbs, below the knee and elbows. The two small bones there may cause problems, particularly with traumatic amputation, and the tourniquet may either not be effective or cause further harm to the casualty. Assess it. Also, if the injury is, for example, below the knee, then don’t put the tourniquet over a joint (i.e. knee), put it above the joint.

  Airway: CLS can aid the airway by positioning (i.e. head tilt/chin lift to open the airway) and use of the NPA. An NPA should be used for any casualty who is unconscious or who otherwise has an altered mental status.

   Consider use of an OPA/NPA and suction. Again, you need to be trained on these items.

   Combat medics are trained to carry out a crycothyroidotomy (‘crike’) to place a breathing tube though the front of the airway. This is an effective way of quickly opening the airway on the battlefield. If you are trained and have the equipment you can use patent airways that insert into the mouth and are of the types that paramedics are be trained to use: Combi-tubes and King Airways.

   A crike will save life but assumes that you are heading to a hospital for treatment and repair. The tube will go through the membrane and this will need to be repaired. However, if it is your option to save life, do it and figure out the details later.

  Breathing: Occlusive dressings are used to close any open chest wounds. Check for exit wounds! Check the integrity of the chest: ribs and breast
bone. You will have to open body armor to do this. If signs of a pneumo/hemo-thorax develop (progressive respiratory distress, late stages would be a deviated trachea (windpipe) in the neck as a result of the whole lung and heart being pushed to one side by the pressure of the air build up in the chest cavity) then needle chest decompression can be performed (NCD).

   If you don’t have a specific occlusive dressing, use something like plastic (or the pressure dressing packet) and tape it down. The Old school method was to tape three sides to let air escape, current thinking is to tape all four sides down to seal the wound.

   NCD involves placing a 14 gauge needle, at least 3.25 inches long, into the second intercostal rib space (above the third rib) in the mid-clavicular line (nipple line). This is basically a little below the collar bone, in line above the nipple. The needle is withdrawn and the cannula is left open to air (tape it in place). An immediate rush of air out of the chest indicates the presence of a tension pneumothorax. The manoeuver effectively converts a tension pneumothorax into a simple pneumothorax.

  o The definitive treatment is to get a chest tube in, in the side of the chest (eighth intercostal space); to drain the blood and air that is filling the chest cavity.

  Circulation 1: At this time, any high and tight tourniquets can be converted to either a tourniquet 2-3 inches above the wound, or if no longer necessary a pressure dressing or packed with kerlix/combat gauze. Any other less serious wounds are dressed at this point with pressure dressings or gauze. Don’t bother with minor cuts and wounds; they are not life threatening at this point.

  Circulation 2: If no distal (wrist or foot) pulse is present (and the casualty in in an altered mental state) then give fluids: 500cc Hextend wide open. If a distal pulse is present, then administer a saline lock in case fluids or medications are required later. Check again 30 minutes later and if the radial pulse is not present, give the second 500cc Hextend bag.