Gun shot wounds and first aid

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The only disadvantage of a pre-made kit.

I see only one disadvantage to pre-assembled medical/first-aid kits. They tend to come in two varieties. The first is about twenty dollars, contains tape, antibiotic ointment and band-aids. Contents worth twelve bucks. The second is fairly pricey, I've seen them go for two hundred. They contain their money's worth of useful equipment. If you're an EMT. The Average Joe isn't going to be putting in sutures, starting I.V.'s, intubating, etc. I strongly believe the relatively untrained (me included. My last formal medical training was over ten years ago) is better off making up a kit based on what they know how to treat and multiple use items. Example, I mentioned I keep laminated posterboard in my kit. Cut square to cover the much talked about sucking chest wound, cut into a cone to cover a damaged eye, make a little tube around a finger to imobilize it, all sorts of stuff. Beats carrying around specific items for each possibility.
 
field procedure

Also:

Some durable stiff paper or cardboard tags with strings and a pencil or good pen.
In treating injured, who are conscious, inquire for their name and city of residence, and especially for allergies they may have. Possibly any existing medical conditions and medications they may be using. Tie, or tape, the tag loosely to wrist, etc.

Recommend to treat for massive bleeding even before restoration of breathing, if it is such a critical condition in which you find the injured.

Urge the walking injured to sit down, even if they feel well.

Solicit help from others, instead of trying to manage all on your own.
 
If you have to treat a casualty with life threatening bleeding AND do something else (move the casualty, solve the tactical problem, etc.) then you are going to need something that is handsfree. Pressure points and direct pressure are great, but require constant maintenance.

Much of the mainstream tourniquet information out there is based on bad tourniquets, in bad environments. I.E. If you tie a tourniquet with a bootlace three days walk from the hospital you probably not have a happy outcome.
 
This is a great thread. There is a bunch of good info although in some cases misplaced priorities. I'm a practicing general & vascular surgeon with fairly extensive PAST operational military experience with specialized small units. I've seen tons of GSWs around the world and unfortunately mostly here in the good ole US of A. I have yet to see a true "sucking" chest wound from conventional civilian or LE bullet wounds. It is far more usual to see a simple pneumothorax (PTX) ("collapsed lung") or a tension PTX. Occluding the wound of a simple pneumothorax can lead to a tension which is usually fatal in the field unless someone reacts and decompresses the chest. I would not recommend sealing up a thorax wound and in fact would be prone to go ahead and stick a needle into the affected side if the patient couldn't breathe (i.e. decompress a tension PTX)

The above points about stopping bleeding are quite cogent. Low velocity bullet wounds (i.e. handguns) work by poking holes in things and making you bleed. Bleed enough and your blood pressure drops. Drop your pressure enough and you first have incapaciation followed ultimately by death if no intervention. Direct pressure better than anything else is the most useful thing you have and should always be the first response.. Believe it or not, duct tape works like a charm; it seals the wound and allows the bleeding to stay contained which in most cases of noncavity wounds will lead to "tamponade" by the pressure and stasis exerted by the expanding hematoma itelf. I rarely advocate tourniquet useage although there have been a couple of instances over the years where applying a tourniquet in the ED has given me time to get the patient to the OR for salvage. In an urban situation that would probably work in the field. In a rural situation that might work and you might end up with a compromised limb. In a remote military environment with poor evac and limited gear/meds/resources/options, those types of wounds are frequently nonsurviveable. If, however, your evac is good and it's a short time to pickup and extraction then this is a viable option. I always try direct pressure and it usually works; not theoretical but real experience. The newer chitosan bandage has done well in the current fracas and can confidently be recommended for use but is relatively speaking costly. I remain less than enthused about the granular hemostatic agents because ultimately you have to pick out all the pieces from what is usually a contaminated wound. There also remains some concern regarding secondary thermal injury although I've not seen enough data to be convinced that this is a serious detriment with the current forumulation.

Regarding the ABC's; they are set up that way for a reason. If someone isn't breathing and you don't fix that the bleeding will stop by itself and not the way you want it to. "All bleeding eventually stops" is a surgical axion and double entendre. Fixable reasons for lack of airway/breathing often require intubation and/or dealing with pneumo/tension pneumo's. This may or may not be within your ability to deal with depending on how much training you have.

Summary advice remains as someone posted above: if they're breathing try to stop the bleeding and get them transported for definitive surgical care. I've seen more folks saved by rapid transport and direct pressure than all else combined.

Regards,

Bob
 
Pressure on the wound and copious expenditure of diesel fuel.

Occlusive dressings are required in two special situations
Three sided occlusive if a sucking chest wound.
Four sided occlusive if wound has comprimised the airway on the neck.

If patient is unconscious, but still moving air (i.e. not dead yet), and you can get them to a level-one trauma center within one hour, there is a very good chance your patient will survive. After that, it don't look good.
 
I'm a working Paramedic. I just want to add my .02. First off aspirin (ASA)... ASA is not a blood thinner as some people believe, it is a platelet inhibitor. If someone gets shot who is on a daily low dose 81mg ASA regimen they are going to clot just fine. Some of the true blood thinners coumadin, plavix, etc and you may have some trouble getting the wound to clot quickly ( it will stop eventually).

As was mentioned earlier tampons make great plugs for larger entry wounds. Some services carry them in their units for just this reason.

As for sucking chest wounds, I have had prob 15-20 gsw's to the torso/chest in the past couple of years ( Waco is a pretty violent city) and not a single one of them has been "sucking." Without a stethoscope it is going to be hard to diagnose the decreased lung sounds of pneumothorax. Your best bet is to cover the entire wound and apply pressure.

Remember to check for exit wounds which are usually larger than the entrance and can cause more problems. Assume that any gsw to the torso hit the spinal cord and keep your pt. still. Trauma dressings (Large sterille dressings) with a triangular bandage tied down tightly over the wound is a good solution for extremity wounds. The easiest way to put it that i can think of is this.... Once you ensure your ABC's are good... If its ugly, COVER IT UP!
 
Summary advice remains as someone posted above: if they're breathing try to stop the bleeding and get them transported for definitive surgical care. I've seen more folks saved by rapid transport and direct pressure than all else combined.
Click to expand...

A few years ago I had a long chat with an MD about this very subject. I guess he was not real busy that day. I went to one of the immediate care places because I had strep throat and needed a prescription.

He was an ER doc before he decided he preferred the better hours working in the walk-in clinic.

He was pretty adamant about getting the guy to an ER rather than trying any fancy first aid tricks. He was not even all that thrilled about waiting for an ambulance to show up. He said he had seen patients die on him in the ER that might well have made it if they had gotten to him 10 minutes faster. Waiting for the FD ambulance to show up probably killed them.

He said he told his wife not to waste time waiting for an ambulance, just cart him off to the ER if he ever had a serious injury. He was dead serious about it too. Of course, this is in town where an ER is pretty close. You might well bleed out if you are 2 hours away from civilization.

He also did a rant about the FD wasting critical time trying to stabilize them before transporting. Something along the lines of making the FD people feel better than doing anything real good for the patient.

He did like the way FDs handle heart attacks. Said they did a good job on them, but did not like the way they handled trauma at all.
 
I'm a working Paramedic. I just want to add my .02. First off aspirin (ASA)... ASA is not a blood thinner as some people believe, it is a platelet inhibitor. If someone gets shot who is on a daily low dose 81mg ASA regimen they are going to clot just fine. Some of the true blood thinners coumadin, plavix, etc and you may have some trouble getting the wound to clot quickly ( it will stop eventually).
Click to expand...

Well actually if you want to get technical there is no such thing as a blood thinner...the blood will be the same thickness regardless of the administration of aspirin, Plavix, or Coumadin...blood thinners are actually a misconception.

ASA and Plavix are both platelet aggregate inhibitors and work in much the same manner albeit at different levels of efficacy. Both do last through an entire platelet life (irreversible).

Comandin prevents blood clots by inhibiting vitamin K-dependent coagulation factor synthesis (II, VII, IX, X, proteins C and S). Coumadin's effect is reversible.

The effect of all of the above mentioned medicine is somewhat dose dependent, but also quite individualized.

One may achieve a a clot on a patient on any of the above medicines under the right circumstances with proper management and time.

Best bet don't worry about those medications and apply direct pressure. Again as I stated earlier training is the key (Honestly I think every outdoors man should know CPR and first aid). Rapid transport is essential with trauma.

He said he told his wife not to waste time waiting for an ambulance, just cart him off to the ER if he ever had a serious injury. He was dead serious about it too. Of course, this is in town where an ER is pretty close. You might well bleed out if you are 2 hours away from civilization.

He also did a rant about the FD wasting critical time trying to stabilize them before transporting. Something along the lines of making the FD people feel better than doing anything real good for the patient.

He did like the way FDs handle heart attacks. Said they did a good job on them, but did not like the way they handled trauma at all.
Click to expand...

Currently most pre-hospital systems that have a director who is educated regarding trauma have shift their focus to a package and ship type mentality. The EMS personnel will spend minimal time trying to stabilize and will focus on packaging the patient and transporting to definitive trauma care ASAP. The will not spend much time in ER either, the patient will go to CT and directly to surgery.

The point being....speed is again of the essence. If you as an individual are faced with a trauma victim then make the 911 call first before treating, it will only take seconds and in many instances the operator has medical training and can assist with questions regarding the medical issue you are facing.
 
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You don't have to be LE/Mil/Paramedic to take courses focused on gunshot wound self/buddy care.

Hugh Coffee conducts focused short courses on this.
 
I can recommend the DTI/Doc Gunn, Inc. POI, as well. Derived from military/LE team programs and adapted for average armed citizen/patrol officer use.

Happily, there are a number of schools offering this type of training now.
 
Yeah, this is going to sound stupid compared to the EMT\doc advice, but if you've never been involved in scouting before there's a lot you can learn there (basic CPR, FA, splints, field dressing, etc, etc). Just a plug as a lot of things I learned have helped at one time or another.
 
What's the shelf life on the Celox or QuickClot? The links provided don't say.

I'd think quite long, since they are sealed up and 'bio inert' until they get used.
 
For Ilbob:

I don't know your doctors experience or when he worked in emergency medicine but things have changed dramatically over the years.

The general emphasis today IS on rapid transport of trauma. I don't know how some EMS systems have evolved, but where I worked as a PM and where I work now (and as taught in BTLS and PHTLS-the general trauma training courses) the gospel is RAPID packaging and transport with treatment enroute to the closest APPROPRIATE facility. The closest community hospital may or may not be the most appropriate facility. Delivering a GSW victim to a small ER at 0400 with no surgeon or OR available or no ICU beds is not going to increase his chances of a favorable outcome.

Problem with grabbing people and driving straight to the hospital is that :

A) the driver is emotionally involved and excited which will affect driving and increase the probability of an accident

B) involvement in an accident will only delay care, worsen the victims injuries, and add other victims to the mix.

C) ground crews might be able to call a helicopter to get that person to a trauma center in minutes, instead of the patient being delivered to a small ER that can't care for him further delaying surgical intervention.

D) medic crews and radio ahead with the patients condition and the hospital can have appropriate resources (blood, OR, surgical staff, specialties, CT scan, etc) waiting for the patient instead of having the patient dropped on the doorstep.

E) people can get lost and not know how to get to the hospital (hey, this ain't TV, I used to go on LOTS of calls where someone got lost trying to race to the hospital with a stroke, heart attack, and YES on more than one occasion a GSW or stabbing)

These are all issues that affect time to surgical intervention which is the only way to deal with life threatening internal bleeding.

Waiting until professional help arrives can be very hard emotionally, but will often result in the patient getting the appropriate care sooner. That can be a tough pill to swallow, I know I've had to choke it down myself on more occasions than I care to count. But keep in mind EMS systems deal with trauma and disasters in every city and town on a daily basis and are generally REALLY, REALLY good at it.
 
brighamr- the advice/input you listed about basic first aid is spot on. I teach the boy scouts locally and was one decades ago. Most of what they still learn involves the basics that will help you out.

sniper5- your comments about EMS are spot on for areas with organized and properly run EMS/Trauma systems. I currently practice in a rural area, and although our EMS guys are well intentioned there are frequently delays like Ilbob listed in his vignette/recollections above. Addtionally, while you are correct about some of the limitations of small community/rural hospitals it actually is sometimes better to locally stabilize in the hospital environment while waiting for evac than to try direct evac/helo from site. Several times per year I see this locally where the patient needed something more than field expedient or prehospital treatment while waiting for transfer to definitive care. Instead I've seen people waiting 45 min for helos when in 15 they could be in my ED and I can resuscitate/package them to go onto a tertiary care/trauma center. I suspect this is not the common scenario but neither is it rare when applied to more remote/rural areas. Previous to coming out here I was in Omaha (which has a nicely organized trauma system as evidenced by their exemplary response to the recent mall shooting). Totally different picture and more in line with your description. Take home lesson is be aware of which paradigm/reality exists in your home turf/AOR.

Glock45guy et.al. - Once again, as the guy who has to debride the wound and put the vessels back together, I am not enthused about granular hemostatic agents. It stops bleeding but is a pain to clean up/debride. This is not a theoretical concern. I suspect the vast majority of my other vascular and trauma colleagues feel the same way. Current military surgeons have had significant experience with both types of chemical/dressing based "hemostats" in Iraq/Afghanistan and by all reports share the above concerns. Again, if you must have a hemostatic dressing then the chitosan dressing is probably what I would recommend. Otherwise good old direct pressure, military battle dressings, duct tape remain excellent and proven options. For perspective, FWIW I do not stock any of those types of chemical hemostat dressings in my home kits preferring to go with the other listed options.

Regards,
Bob
 
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Special tourniquet are certainly a very good idea, but it's my opinion that we all need to know how to adapt to situation when top-of-the-line equipment isn't available. Ideas like this tampon styptic impress me. But it's surprising to know how many people don't know a lifesaving tourniquet can be made with such simple items as a cloth and a stick.
 
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