On National Peace Officers Memorial Day–and every day–we honor the memories of those officers who lost their lives while upholding their oath to protect their communities and the country. We also remember the loved ones and friends they left behind. May they know we share in their suffering. God bless those officers who gave the ultimate sacrifice.

From Calibre Press | calibrepress.com

Being trained and prepared to immediately respond to an injury or other medical emergency in the field can literally make a life-or-death difference. That life can be a fellow officer’s…or yours. Dr. Martin Greenberg is an orthopedic surgeon who is also a police officer, SWAT operator and tactical medic. His mission is to give officers the information they need to handle a wide variety of injuries that may be suffered during the course of police work.

He has written an important book titled The Law Enforcement Medical Encyclopedia: Navigating Medical Challenges in a Dangerous World. Dr. Greenberg has agreed to share a few chapters from his book in the interest of getting this information into as many officers’ hands as possible as quickly as possible. Over the next few months we will intermittently share several chapters. If you would like to order the entire book—which we highly recommend—information on where you can get a copy will be included at the end of each excerpt.

We begin with a chapter titled Self-Aid/Buddy Aid:

Much has been written about self-aid/buddy aid including what “aid” entails, where it should be appropriately administered and what gear will be needed. Self-aid/buddy aid could more specifically be termed field bleeding and airway management. This may be directed towards oneself or others.

The Tactical Casualty Combat Care committee (TCCC) has published recommendations regarding the appropriate settings to provide this care. Here, we will discuss the medical threats of hemorrhage and airway compromise and their field treatment.

Vascular Anatomy of the Arm and Leg

Arteries and veins are the conduits carrying blood away from and back to the heart. Arteries are the thick-walled vessels carrying pressurized oxygen rich blood from the heart while veins are thin walled and carry low pressure oxygen poor blood back to the lungs and heart to receive more needed oxygen for the next circuit around the body.

Since oxygen rich arterial blood is pressurized, an arterial laceration may appear to pump bright red blood. Alternatively, a venous laceration will release a constant flow of darker red blood. Incomplete arterial and venous lacerations will generally bleed more than complete vessel lacerations. This is because the arterial wall muscle layer contracts around the zone of vessel injury. An incomplete laceration will be enlarged by this contraction while a complete laceration will tend to squeeze and shut the vessel’s cut end. Small lacerations may therefore bleed profusely while large injuries or even limb amputations may only bleed minimally.

The major artery travelling along the inner arm between the shoulder and the elbow is the brachial artery. The radial and ulnar arteries are the two major arteries of the volar or palm side forearm. There are many veins carrying blood back to the lungs from the upper and lower extremity.

In the leg, the femoral artery is the major vessel travelling down the inner thigh carrying blood down the leg. It traverses the back of the knee as the popliteal artery and splits into the anterior and posterior tibial arteries in the leg. We describe the lower limb between the hip and the knee as the thigh. The area between the knee and the ankle is termed the leg. Again, many veins are present in the lower extremity carrying blood back to the lungs and heart.

Extremity Hemorrhage Control

Evaluating extremity bleeding requires some thought. First, is the bleeding minor or profuse? If profuse, is it pulsatile or constant? Both minor and non-pulsatile bleeding will likely be controlled with a pressure dressing. Pulsatile bleeding will likely require a tourniquet for hemorrhage control.

In the absence of pulsatile bleeding, I recommend applying a pressure dressing. This involves tightly packing the open wound with medical roller gauze or gauze pads and covering the wound with gauze pads or an abdominal (ABD) dressing and an elastic-type bandage if available. Using nitrile gloves is recommended if they are available. Sterility is not a concern applying a field pressure dressing. Lack of significant bleeding through the dressing means success.

Helpful commercial products in pressure dressing application are the OLAES® and the Emergency Bandage®. The Emergency Bandage® was developed by the Israeli Defense Force and introduced to the civilian market in 1998. It combined the elastic dressing and a tourniquet in one dressing. It is available in multiple sizes and has extremity and torso variants. It is quite versatile and it can be applied as part of an extremity splint or even as a head wound dressing. It is currently available through Persys Medical (www.ps-med.com) along with internet video application instruction.

The OLAES® Modular Bandage is a recent popular variant of this type of compression dressing. It is also available in multiple sizes and includes a pressure cup that can be used as an eye shield, a removable occlusive plastic sheet and three meters of medical gauze. It eliminates the windlass present of the Emergency Bandage and has several Velcro® control strips to maintain its integrity. It is currently available through Tacmed Solutions, Inc. (www.tacmedsolutions.com).

Hemostatic Agents: Exothermic v. Normothermic Agents

The first hemostatic agent to be used in field medical care was Quik Clot® produced by the Z-Medica company in 1984. The active agent was zeolite that promoted blood clotting via an exothermic (heat releasing) reaction. In its original form, the heat produced caused local tissue death and significant burns. This reduced its usefulness as it could not be used in conscious victims and it made later vascular repair more difficult.

The active agent was then changed to kaolin, a silicate mineral also known as China clay. It is normothermic (does not produce heat) and is marketed commercially as Quik Clot Combat Gauze® and other products through multiple vendors.

Another currently popular hemostatic agent is Celox®. Celox® is a normothermic hemostatic agent using chitosan, a natural polysaccharide. When exposed to blood, the chitosan granules swell, clot and eventually are metabolized. Celox® is marketed as a granular packet or as Celox-A® (an injectable applicator) or Celox Rapid Ribbon® (a one inch wide gauze strip). In my opinion, the granular form of either product is ineffective as it will not stop arterial pulsatile bleeding and isn’t needed for venous bleeds as a pressure dressing will suffice. Celox-A or Rapid Ribbon are capable of delivering Celox thru a gunshot entry wound to an arterial laceration when appropriately injected or packed in the wound.

Tourniquet Use/Recommended Tourniquets

The purpose of a tourniquet is to stop arterial blood flow to an extremity below the level of the tourniquet. There is historically a difference of opinion regarding when a tourniquet should be applied. About twenty years ago, the law enforcement literature uniformly stated that applying a tourniquet was consigning the involved limb to amputation. Even then, this seemed illogical to me when as an orthopedic trauma surgeon I had applied surgical tourniquets to arms and legs thousands of times for up to two hours with no adverse effects.

Since then, tourniquet use has gained popularity and is frequently recommended as the primary treatment for any type of bleeding. Despite its benign nature when used for less than two hours, in my opinion a pressure dressing is preferable when treating non-pulsatile bleeding. If a pressure dressing is unavailable or fails to successfully stop what is felt to be non-pulsatile bleeding, then tourniquet use is appropriate.

Even tourniquet application technique is somewhat controversial. It is frequently taught that the tourniquet should be applied “high and tight” meaning just below the shoulder or hip regardless of the level of injury and as tight as possible. Tourniquets should not be applied over joints as there is a bony impediment to their function. After exposing the wound, tourniquets should be applied several inches above the injury to avoid unnecessarily involving the uninjured parts of the extremity. They should be tightened until the bleeding ceases and no more. Unnecessarily high pressure may injure local skin under the tourniquet.

Once applied, the tourniquet may be left in place for up to two hours. The time of application  is prominently written on the victim’s forehead with an indelible Sharpie® marker or on the Combat Application Tourniquet® (CAT tourniquet) in my practice. Inadvertently leaving a tourniquet on, hidden under splints or dressings, beyond the two-hour time limit is a serious error. Hopefully, definitive medical care can be obtained during this two-hour timeframe. Personally accompanying the victim while the tourniquet is applied is strongly recommended if possible.

There are many tactical tourniquets commercially available. Generally, positive tourniquet attributes should include ease of consistent application, width and resistance to failure with extremity motion. The most popular tourniquets have gone through several versions to improve their function and have been tested in multiple studies. They are the Combat Application

Tourniquet® (CAT), the Special Operation Forces Tactical Tourniquet® (SOFT-T) and the Tactical Mechanical Tourniquet® (TMT). Applying the tourniquet one-handed on the opposite injured upper extremity is a degradable skill and requires periodic practice. The goal is to successfully apply the tourniquet to the opposite upper extremity in thirty seconds.

The tourniquet should not be unbuckled during this application and should be stored in a folded manner to allow immediate application. Lower extremity self-application usually requires unbuckling the tourniquet and two-handed application is recommended. Facsimile (usually Chinese) tourniquets marketed as one of the popular brands are common and care should be taken to purchase the real product from reliable vendors.

In a recent study, the CAT Gen. 7 tourniquet was the fastest to apply and the least subject to failure with active extremity motion compared with the SOFT-T (wide) and the TMT. (1) These are windlass type tourniquets relying upon windlass tightening for effective function.

Other tourniquets include elastic, ratcheting and pneumatic types. Tourniquets have even been integrally included in tactical operator’s clothing. The CAT is recommended by the TCCC (Tactical Combat Casualty Care committee). The CAT and the SOFT-T (W) are the most currently accepted civilian tourniquets. Internet video application instruction is readily available by their distributors. I do not recommend elastic tourniquets in general due to their inherent variability in application and the increased possibility of local tissue damage due to excessively high pressure and possibly narrow application.

One-handed application in the upper extremity is also difficult to impossible. I recommend purchasing a CAT or SOFT-T (W) tourniquet and practicing with it to achieve application proficiency. You are also most likely to receive one of these tourniquets if they are issued to you professionally or in an emergency. Having even more than one tourniquet readily available on either side of the body for easier one-handed application deserves consideration.

Remember to use training items for training only. Do not carry training tourniquets operationally. Storing the tourniquet as part of an Individual First Aid Kit (IFAK) or “blowout” kit is highly recommended. The American College of Surgeons has developed an international course to train civilians and first responders to control hemorrhage called STOP THE BLEED®. This program was begun, as the American College of Surgeons notes on its website (www.stopthebleed.org), through a National Security Council federal initiative to raise public awareness of the problem of exsanguinating hemorrhage and to treat it.

The American College of Surgeons was founded in 1913 and has more than 82,000 members. Its committee on trauma oversees the program that has two phases. In phase one, basic hemorrhage principles are outlined. This phase can be taken in person or online. Phase two is an in-person workshop practicing the skills of applying a pressure dressing and a tourniquet led by a STOP THE BLEED® instructor.

It emphasizes the four steps of hemorrhage control:

  1. Call 911
  2. Apply pressure with both hands
  3. Pack the wound and press
  4. Apply a tourniquet.

This course saves lives. The state of California and many municipalities have hemorrhage control kits available in public facilities similar to automatic external defibrillator (AED) availability. Hopefully, this action will gain increasing future popularity.

Airway Management Including Pneumothorax and Tension Pneumothorax

Airway management at the first responder level involves managing a patent airway. Simple obstructions in the mouth or upper pharynx (the back of the mouth) can be removed with a digital sweep maneuver. This involves placing the index finger deeply into the mouth and sweeping it from one side to the other. This is most successfully performed on unconscious victims.

Other maneuvers to restore patency to the upper airway in a supine victim are the head tilt/chin lift procedure where the head is tilted slightly back and this may move the tongue away from the upper airway. The jaw thrust is a maneuver where the angle of the jaw is grasped on both sides with the index and long fingers. The posterior (back) of the jaw is then pushed up and forward while the thumbs are used to open the mouth if needed.

These simple maneuvers may be performed simultaneously and they are taught in most basic first aid classes. Although they are simple, instruction and practice are recommended. The adult recovery position is also described as a way to maintain the chin lift in an unconscious victim in a mass casualty triage situation. Here, with a supine victim the near arm on “your” side is extended at 90 degrees to their torso. The opposite or far leg from you is bent at the knee and the victim is turned toward you. Their opposite or far hand is then placed under their extended chin. This helps maintain the patent airway and keeps secretions from draining down the airway when a victim cannot be continuously supervised. Again, practice is recommended.

A nasopharyngeal airway (NPA) is a latex tube placed in the nares (nose) of a semi-conscious or unconscious victim to help maintain a patent nasopharyngeal (nose and upper throat) airway. It has a collar on one end to prevent over-insertion and an angled tip. The recommended adult size is 28FR (French). It should be lubricated with an available lubricant and inserted with a back-and-forth rotating motion directed back and not up. The tip angle should be directed to the nasal septum (nasal midline). It should be fully inserted. Do not use this device in the presence of significant nasal/facial trauma and training is definitely recommended.

A pneumothorax or collapsed lung results from a loss of the vacuum seal keeping the lung “attached” to the chest wall. This is usually due in a trauma setting to a puncture wound or laceration of the chest wall. When we breathe, our brain sends a message to the diaphragm through the phrenic nerve. This nerve is innervated by the third, fourth and fifth cervical nerves

in the neck. There is an old medical saying, “C 3, 4 and 5 keep the diaphragm alive.” The diaphragm then acts like a bellows by increasing the space in the chest cavity. Because the lung is vacuum sealed to the chest wall and diaphragm, it expands and air is drawn in. We experience this as inhaling or breathing in. When the diaphragm relaxes, air is forced out of the lung as the chest cavity shrinks. We experience this as exhaling or breathing out. When the vacuum seal is broken by a puncture or laceration, the lung is no longer connected to the chest wall.

It then no longer moves with the chest wall and diaphragm in respiration. Luckily, we can still breathe quite well with one intact lung. This is called a simple pneumothorax and it is not an immediate life-threatening field emergency.

However, a complication may arise if the laceration or puncture wound acts as a one-way valve allowing air to enter the chest cavity on the involved side but not to exit. Then, an enlarging air bubble develops on one side of the chest cavity with every breath. The enlarging air bubble pushes the collapsed lung, the heart and great vessels and even the opposite lung away from it to the opposite side of the chest. This progressively compromises the opposite lung’s function and obstructs blood returning from the body to the heart and lungs.

Clinically, progressive dyspnea (difficulty with breathing) occurs. The neck veins protrude, and the neck and face may appear progressively cyanotic (red or bluish red). This emergent problem is called a tension pneumothorax. It may be prevented by applying a gauze or commercial chest seal dressing over the puncture wound. An established tension pneumothorax is treated by decreasing the size of the enlarging air bubble. This is done by inserting a 14G Angiocath® catheter at least three inches long through the chest wall into the air bubble. The recommended location for insertion is the fifth intercostal space in the mid axillary line of the thorax. In English, this means insertion between the fifth and sixth rib in the mid lateral line of the involved chest wall. If successful, a gush of escaping air will be heard through the catheter. Breathing will immediately improve. The Angiocath® catheter or commercial tension pneumothorax treatment needle is taped in place and left patent until definitive care is rendered. Training is definitely recommended to perform this procedure but remember that it is a time sensitive, life and death problem!

The Immediate First Aid Kit (IFAK) or “Blowout” Kit

Having a compact kit to control bleeding and simple airway problems is highly recommended for law enforcement professionals, armed citizens and the general public. The name and contents of this kit varies by vendor, but it is generally called an Immediate First Aid Kit (IFAK) or “Blowout kit.” The kit is intended to be used on its owner. Larger kits called Mass Casualty Injury (MCI) kits are available for those events. Retired DEA agent Chuck Soltys has dedicated himself to training as many law enforcement officers as possible in the use of his custom Blowout Kit that we will describe here. (2) The kit can be divided into basic and advanced items.

Basic Items:

  • one Emergency Bandage® or Olaes® dressing;
  • one pair of trauma shears;
  • two pairs of nitrile gloves;
  • one mini sharpie marker;
  • one small Ziploc bag;
  • one tactical tourniquet;
  • eight strips of 2 or 3” duct tape;
  • one roll of masking tape.

Advanced items:

  • Two 14G Angiocath® needles at least 3” in length;
  • one size 28FR nasopharyngeal airway (NPA);
  • one hemostatic agent either Celox® or Quik Clot®. (The

Celox-A® tampon is my personal choice).

The duct tape strips are buddy taped at their ends to allow for quick use. All the items are taped together with masking tape and can easily fit into a pants cargo pocket. Training in the use of all the kit’s components is necessary and recommended. After appropriate training, keeping the kit on your person when in the field is crucial as one never knows when the need may arise. There is a famous law enforcement saying that “Guns are like parachutes. If you don’t have one when your need it, then chances are that you won’t ever be in need of one again.” (3) In my opinion, the same may be said for the IFAK.

References:

1 Traeger et al., J Trauma Acute Care Surg. 2021

2 Soltys, C.-Assembling a blowout kit for patrol, Police One, 2009/2018

3 Rawles J.W.-Tools for Survival, Plume Books, (2009), p. 188

The Law Enforcement Medical Encyclopedia: Navigating Medical Challenges in a Dangerous World is available directly from the publisher, Dorrance Publishing Company, by clicking here or calling (800) 788-7654. It’s also available on Amazon here.