“I am dying.”
This was the tweet posted by Oleysa Zhukovskaya, a 21-year-old woman who volunteered to work as a medic during the Ukrainian revolution in early 2013. Government snipers were targeting medics (who were marked with red crosses) and journalists. Zhukovskaya was struck in the neck by a bullet.
Seeing this drama unfold, I considered long-term survival scenarios in which civil unrest and other events could put the group medic in harm’s way. This might involve situations in which the medic is with his/her group in foraging operations or simply at “base camp” when hostile forces arrive, as happened in the Ukraine.
Our young medic might have thought a red cross identified her as a “noncombatant” and, thus, made her immune to enemy fire. Indeed, firing on a clearly marked medic is considered a war crime by the Geneva Convention. Unfortunately, few respect the Geneva Convention these days and have no problem shooting noncombatants. Some even use children as shields.
We should realize that if the defecation hits the oscillation, medical personnel are fair game. In fact, killing the medic is a time-honored way to damage morale and decrease a unit’s effectiveness. Avoid wearing a big, white armband with a red cross; it won’t protect you. U.S. combat medics today wear much less-noticeable insignia.
In the military, it’s clear who the medic is. In survival, the same should be true. Most hostile encounters will be unexpected, and not having assigned someone in the foraging party as the medic might lead to paralysis on the part of group members as to who needs to attend to a casualty.
Practical Priorities for the Survival Medic
Doing the right thing at the right time is the cornerstone of tactical combat casualty care (TCCC). The Committee on Tactical Combat Casualty Care (CoTCCC) developed a re-evaluation of care with a specific goal in mind: to decrease preventable deaths from hostile encounters. One in five deaths from hemorrhage in these situations might be prevented with quick, rational action. It is thought that 2,500 combat deaths occurred in Vietnam due to extremity hemorrhage, some of which might have been avoided by following current TCCC recommendations.
… KILLING THE MEDIC IS A TIME-HONORED WAY TO DAMAGE MORALE AND DECREASE A UNIT’S EFFECTIVENESS.
While the CoTCCC focuses on military engagements, the strategies put forth work in any unsafe environment. Not only are these strategies prudent in survival settings, they might also save lives in active-shooter events.
It should be noted that actions appropriate for the medic facing hostile fire are different from what you might consider to be the practice of “good medicine.” In these situations, good medicine could be bad tactics—and that could get people killed, especially the medic.
This poses the question, Should medics be armed? Because the “gentlemen’s agreement” that protects medical personnel in a combat scenario is rarely taken seriously by the enemy, the answer can only be … Yes. The most important goal in this case is to abolish all threats, and this means helping provide suppressive fire when needed. The best medical care when under fire is eliminating the enemy—or at least keeping their heads down and weapons silent.
This philosophy might be difficult to absorb for the medic, because they will want, first and foremost, to selflessly attend to wounded comrades. Without dealing with the threat, however, they are likely to become the next casualty if they run into the line of fire. History shows us that this was a common way for medics to meet their demise, sometimes on the way to evaluate casualties who were already beyond help.
Another issue for the medic is that many of the standard medical tools used to evaluate a victim will be useless in a firefight—forget trying to listen to a casualty with a stethoscope if there is gunfire. In addition, it’s foolhardy to use a headlamp at night to treat the wounded unless you have cover; it might as well be a target bull’s-eye.
When under fire, therefore, here are my thoughts on what your priorities as medic should be:
- Abolish or suppress the threat. Remember: The best medicine is fire superiority. Additional suppression provided by the medic might be essential to achieve this goal.
- Determine the level of consciousness of the injured party. If the casualty is alert, direct them to get to cover and begin self-aid. If they are clearly exposed and can’t move to cover, direct them to lie flat and motionless so as not to attract fire.
- Avoid exposure to enemy fire while attempting to reach the casualty. Clearly, this is easier said than done, but getting shot isn’t going to help your injured group member.
- Once there, get the casualty and yourself to reasonable cover if exposed. Don’t confuse concealment with cover. Kneeling behind a rose bush might constitute concealment, but it doesn’t stop bullets. While providing aid, position yourself so that you can see likely areas of hostile advance.
- If the casualty has altered mental status, disarm them. If alert and oriented, have them continue to return fire—or at least assist you in providing first aid for their wound.
- Assess the wound(s) quickly but thoroughly, including the back and head. In the case of a life-threatening extremity hemorrhage, use tourniquets as a first line of action.
You might ask, “When is bleeding life threatening?” This seems like a simple question, and it will often be obvious. The presence of bright-red arterial bleeding that spurts out in correlation with the victim’s pulse is one sign that you must act quickly. When an artery is traumatized, you will likely have only a few minutes to save a life.
Steady bleeding from veins, however, can be as dangerous, especially when clothes are soaked and blood pools on the ground. When simple, direct pressure fails to slow bleeding, and bandages become saturated, it is clear your casualty is in trouble. Of course, a traumatic amputation of an extremity is another example of when bleeding might be life-threatening. All these victims could be in various degrees of shock, pale, confused or unconscious.
Use of Tourniquets
When a tourniquet can be applied, it is the first course of action that should be undertaken. Traditional restrictions on tourniquet use were based on issues such as losing a limb due to cutting off the circulation. In the end, losing a limb is preferable to losing a life.
JUST BECAUSE A TOURNIQUET IS INITIALLY SUCCESSFUL IN STOPPING THE BLEED, IT DOESN’T MEAN THAT IT CAN’T RESTART. CONSEQUENTLY, FREQUENT REASSESSMENT OF THE WOUND AND TOURNIQUET PLACEMENT IS IMPORTANT.
In a 2008 study of 232 instances in Iraq when tourniquets were used on 309 extremities, no amputations were necessary due to lack of circulation. Three percent of casualties had temporary nerve damage. The study, published in The Journal of Trauma, concluded that tourniquet use for two hours or less resulted in few complications. Indeed, in some modern surgical procedures, tourniquets are left in place for longer periods of time.
Which tourniquets are preferred by the military for care under fire? The CoTCCC recommends two tourniquet brands: the CAT (Combat Application Tourniquet) Gen 7 and the SOFT-T (Special Operations Forces Tactical Tourniquet). This preference is based on previous reviews of their effectiveness in the field, but these items also have the advantage of ease of use with one hand. This is not to say that other brands might not be effective. Various types of tourniquets are on the market, and each has its own characteristics.
Although a basic aspect of care when not under fire is fully exposing the wound, this takes time. As a result, apply the tourniquet over clothing; and, unless you know the exact extent of the injury, apply it “high and tight.” That means significantly proximal (closer to the torso) to where the bleeding appears. Later, when the encounter is over, the wound can be better evaluated, and the tourniquet can be converted to a different position, if appropriate.
Don’t be surprised if tourniquet application is painful to the injured group member. If applied properly, it should hurt. In addition to stopping the bleeding, correct application should also stop pulses distal (farther from the torso) to the wound.
There will be times when one tourniquet is not enough. If the first tourniquet fails to control the bleeding, apply a second tourniquet above (proximal to) the first. Avoid placement over a joint, and be aware of items in pockets or folds and bunches in clothing that could prevent adequate pressure application. Just because a tourniquet is initially successful in stopping the bleed, it doesn’t mean that it can’t restart. Consequently, frequent reassessment of the wound and tourniquet placement is important.
Do not remove or loosen the tourniquet while still under fire, especially if the casualty is in shock, an extremity has been traumatically amputated or you cannot closely monitor for re-bleeding. When things quiet down, however, every effort should be made to convert tourniquets in less than two hours if bleeding can be controlled with other means.
Other Ways to Stop Bleeding
This can be achieved with Combat Gauze, a bandage impregnated with Kaolin and made by QuikClot. The CoTCCC also accepts the use of CELOX Gauze or ChitoGauze—dressings that contain chitosan. These products are called “hemostatic agents,” which means they help stop bleeding by either helping the body form a clot or by forming a clot themselves. Hemostatic and other bandages are also important for non-extremity bleeding. QuikClot Combat Gauze is the preferred product of the CoTCCC, but CELOX Gauze and ChitoGauze might be especially useful in casualties with depleted clotting factors due to massive hemorrhage.
AVOID EXPOSURE TO ENEMY FIRE WHILE ATTEMPTING TO REACH THE CASUALTY. CLEARLY, THIS IS EASIER SAID THAN DONE, BUT GETTING SHOT ISN’T GOING TO HELP YOUR INJURED GROUP MEMBER.
Placing the hemostatic bandage involves tight packing directly on the bleeding blood vessel after removing any previous dressings. Application of direct pressure is then conducted for a full three minutes. A pressure dressing, such as the Emergency Bandage (also known as the Israeli Battle Dressing or IBD), is then used to cover the wound. Leave the loosened tourniquet in place for quick re-application if needed. If the bleeding is not controlled with Combat Gauze, re-tighten the tourniquet until bleeding stops. Tightening enough to eliminate the distal pulse will help ensure the application was effective.
Notice that I don’t mention airway management or cervical spine immobilization while under fire—two basic steps in evaluation, care and transport of victims of trauma in a safe environment. This is good medicine, but control of hemorrhage will be the most likely way you’ll save a life in this scenario. Airway or cervical spine injuries play less of a role in injuries from most hostile encounters. You don’t have the luxury of time to do much else, so concentrate on stopping hemorrhage.
When the Shooting Stops
When you are no longer under fire, a more comprehensive phase of medical evaluation and treatment, known as “tactical field care,” can then be initiated. This is followed by evacuation (CASEVAC) to your hospital tent or wherever the bulk of your survival medical supplies is located. This duty is difficult enough for military medics, even when helicopter rescue and modern field hospitals are available. The survival medic’s job is even more difficult because of limited supplies and transport options and the responsibility to deal with the wound until full recovery is achieved.
Cross-Training Can Be Critical
Something apparent to me in these settings is the importance of cross-training. Everyone in your group should know how to apply a tourniquet correctly to themselves and others, as well as other basic hemorrhage-control strategies.
If the medic is the wounded party, the ability to give concise instructions to others could save a life (yours!). If you are the medically responsible member of your group, think about what you would tell other group members to do if you were bleeding, had broken a bone, were sick, or had other health or medical problems. The more people who know how to deal with medical issues, the higher the chances to succeed, even if everything else fails.
Tactical combat casualty care is challenging and complex, especially under fire. I have the highest respect for the combat medic, who has a tough job in the best of circumstances. The survival medic has a tough job, too, and must understand that the compulsion to do good can sometimes be hazardous to their health. Abolish the threat, have the right supplies, and you’ll save more lives … maybe even your own.
By the way: Our Ukrainian medic, Oleysa Zhukovskaya, was transported to the hospital and survived.
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Combat Casualty Care Training Courses
If you have the intestinal fortitude, there are many combat casualty care training courses out there. One demanding, but useful, one is conducted by the folks at Talon Defense. There, you’ll be put through rigorous simulations of live-fire scenarios and learn, hands-on, how to deal with wounds in the chaotic atmosphere of a hostile encounter. If you’re interested, you can find videos of “team runs” on YouTube.
Care Under Fire
This article contains my thoughts on medic actions during hostile encounters. Below are the official recommendations of the 2017 CoTCCC for care under fire:
Basic Management Plan for Care Under Fire
- Return fire and take cover.
- Direct or expect the casualty to remain engaged as a combatant, if appropriate.
- Direct casualty to move to cover and apply self-aid, if able.
- Try to keep the casualty from sustaining additional wounds.
- Casualties should be extricated from burning vehicles or buildings and moved to places of relative safety. Do what is necessary to stop the burning process.
- Stop life-threatening external hemorrhage, if tactically feasible:
Direct the casualty to control hemorrhage by self-aid, if they are able.
Use a CoTCCC-recommended limb tourniquet for hemorrhage that is anatomically amenable to tourniquet use.
Apply the limb tourniquet over the uniform clearly proximal to the bleeding site(s). If the site of the life-threatening bleeding is not readily apparent, place the tourniquet “high and tight” (as proximal as possible) on the injured limb and move the casualty to cover.
- Airway management is generally best deferred until the tactical field care phase.
Besides hemorrhage, open chest wounds might cause the collapse of a lung, also known as a “tension pneumothorax.” In this case, wipe away blood and place a vented chest seal (Hyfin, Asherman, FoxSeal or another brand) directly over the entry and (if present on the chest) exit wounds.
A chest seal can be improvised with a plastic bag or other occlusive item taped over the wound on three sides. This will allow air that is causing pressure on the lung to leave the chest cavity and allow the lung to re-inflate. This is a temporary solution, but it might give you time to get the casualty to where more-advanced care can be rendered.
Editor’s note: A version of this article first appeared in the March, 2018 print issue of American Survival Guide.