Last month I attended a four-hour class designed to teach average folks the basics of using gauze, tourniquets and compression bandages in situations where there has been a life-threatening injury. The idea of the course is to provide sufficient care to keep people alive until emergency responders can arrive. Some forums I'm on have a place for course reviews or after-action reports, but after PM with Blast, he said it would be OK to put mine here.
The Essential Medical Care Course was taught at Weyer Tactical in Alliance, OH -
http://www.weyertactical.com This review has become kind of long, so for the short version: I thought this was a very worthwhile course, quite reasonably priced ($50), taught well. I look forward to future chances to attend other courses with these instructors. Almost worth the price of admission on its own – a couple tips for improvising tourniquets and compression bandages on the cheap (I'll share them below). I have no affiliation with Weyer Tactical - just took the course and I liked it.
There were 9 students in the class. My only previous medical training was Red Cross Basic First Aid and CPR, about 5 or so years ago. This seemed to be about the average for the group, while several had had first aid courses they had learned in the military. The big thing I remember from basic first aid was “Call 911 first, then provide care.” The care pretty much topped out at “apply gauze and use direct pressure.”
The class was taught by Shaun Baskerville, whose background includes service as a Marine, and he is currently working in law enforcement, including as a member of a Special Response Team and Tactical Emergency Medical Support. While Shaun led the class, he got input from Joe Weyer (pronounced “wire”), the owner and instructor of Weyer Tactical, whose background includes service in the Army and current work in law enforcement. Bill Clark, an Army Ranger and current National Guard member, is also an instructor and he offered his insights.
We used the “crawl, walk, run” method of instruction. Shaun would explain things with a Powerpoint presentation – like describe and show pictures of injuries. Then he would demonstrate the use of, say, a tourniquet, and then we would partner up and practice using them.
The Powerpoint started off with a picture of a fairly nondescript city street and sidewalk shots. Shaun asked if we knew what this was – someone figured out it was the scene of the Boston Marathon bombing, prior to the race. The bombing was just a couple weeks old when we had the class, and he used it as a reminder that serious injuries can happen with little to no warning – anything from a car accident to a shooting range accident to a nasty fall around the house could make these skills vital.
Some of the photos were extremely graphic – profuse bleeding, clothing blown off people, smoke/burns on their flesh, amputations. But they weren't used gratuitously – they were shown in part to give an idea of wounds you might see – and to show that even though these things can look horrendous, these people can be helped and can survive with prompt, competently applied aid. One of the big mindset hurdles that this class helped me overcome was to begin to look at the injuries, get over the “ick” factor, and start thinking about “if I ran into a situation where someone was hurt like that, what could I do to help?”
We got an introduction to how to assess an injury, and how to pick which tool (or tools) would be needed. Using photos, videos and verbal description, Shaun laid out a rough guide of how to make the selection, and then we learned how to apply them.
The triad of simple tools to help in case of serious injury? A tourniquet, gauze, and a compression bandage. Ideally, gauze impregnated with a hemostatic agent like QuikClot or Celox. But apparently, the advantage with the hemcon agents is in the 5% range or so – so it's an advantage, but not an overwhelming one, and good results can be had with some variant of plain gauze.
First off, he showed us an array of top commercial tourniquets, starting with the North American Rescue Combat Application Tourniquet, or “CAT” for short; the SOF-Tactical Tourniquet or “SOF-T” These two are pretty similar – a buckled loop of nylon webbing that you put over a limb and tighten similar to how you'd tighten a belt, then a “windlass” [a sturdy length of metallic bar] is cranked in a circle until it tightens enough to restrict circulation and stop the bleeding in the extremity. Bill stepped in to show the Tourni-Kwik TK4 – basically a length of elastic about 2 inches wide and roughly 18 inches long, with padded metal hooks on either end. With this, you drape it over the limb you're working on, hook one end over elastic, then pull in the opposite direction and continue to wrap tightly until the bleeding has stopped, then secure the second hook to the edge of the elastic.
We got time to rotate through and try all three of these commercial tourniquets, plus an ingenious improvised tourniquet that Shaun introduced us to.
He broke bleeding down into two different types – a veinous bleed, which shows dark blood, and accounts for the majority of cuts you usually see, from papercut up to some pretty serious injuries. Arterial bleeding is notably different for the bright red oxygenated blood, and it's usually squirting out of the body to the rhythm of the heartbeat. In the case of a severe arterial bleed, Shaun said an untreated victim will have about a minute of conscioiusness, and three to five minutes left to live.
So, what did I learn here? If you see an arterial bleed, you don't want to have to try to improvise a tourniquet – you want a purpose-built tourniquet, and one that's ready to apply RIGHT NOW.
I also learned I don't want the first time I ever try to put a tourniquet on someone – or myself – to be when I NEED to do it. Although the mechanisms on all of them are pretty simple, I found myself fumbling around a bit. When I tried putting one on myself, I sometimes snugged the belt tight, only to find that it put the windlass in a place I couldn't reach to perform the final tightening of the tourniquet. I'd seen pictures of all three of these models online prior to the class, but it was invaluable to be able to try them all out, get a feel for them, and try applying them to other people and to myself.
Finally, on tourniquets: Once you put one on, YOU DO NOT REMOVE IT. In a hospital setting, the ER or trauma specialists are going to be the people to deal with it. Tourniquets can remain on safely for hours and hours – we (those of us who aren't medical personnel) might run into a situation in our lives where we need to put one on someone, but I couldn't come up with an example of when we would be the ones to take them off.
The next simple tool was rolled gauze – either with a hemosatic agent like Quikclot or Celox – or just plain Kerlix. We saw video of it being used to stop arterial bleeding. Seeing it online was different than practicing the maneuver. I had envisioned packing a wound to be inserting gauze into a wound to absorb blood in place. But as Shaun and Joe explained, the pressure of the blood will dislodge the gauze unless it's packed in so tightly that it's not just absorbing the blood – it's a physical barrier, like a cork in a bottle. We practiced making a loose fist and packing gauze into our own hands, then into the cupped hands of a partner (simulating a large wound, like the exit wound of a gunshot). That was helpful, but the lightbulb moment came for me on this exercise when Joe circulated among those of us trying it out, and he packed the gauze into my cupped hands. Feeling it done right made it all clear.
Around this time, Joe took a moment to bring home to the class how hard intervention can be. He said he's been on the scene to treat several people with severe bleeding, including gunshots. And he said that effective treatment will usually be more painful than the initial injury, including gunshots. The injured person may tell you to stop it – grimace, scream, try to punch you. But if it's truly a life-threatening injury, you can't stop thet treatment because it's painful. These reactions are normal, even – and perhaps especially – if you're doing it right.
Shaun then introduced the final critical tool – a compression bandage. We tried the Israeli bandage and similar setups. Basically, they're a thick absorbent pad attached to a wide elastic band. They somewhat bridge the gap between direct pressure and a tourniquet – they cover and protect a wound, and as it tightens it can help decrease blood loss. And once it's set, you can still use direct pressure on top of the compression bandage.
He walked us through their use – on their own for some wounds, and as a tiered approach for more grave injuries. He also helped bring some of the real-world perspective: Ideally, your items are sterile, you’ve got clean gloves on, the victim’s on a clean surface. But in the real world, he said if he drops the gauze or bandage in the dirt, oh well, he’s going to pick it up and use it. Once the victim gets where he’s going, there’s going to be a well-paid surgeon or ER doc there to handle cleaning up whatever’s packed into the wound, and shoot the victim full of antibiotics. The crucial thing is to provide that lifesaving intervention to bridge the gap.
So, as the lecture wound down, they had one last surprise for us. Joe had us all turn toward one wall as the surprise passed through the room to get in place behind room dividers. Shaun then explained that we were going to put our practice with the tools to the test. They had volunteers who were set up in three separate injury scenario stations. Shaun, Joe and Bill each took over one of the scenarios. They told us what to expect – when we entered the individual rooms, we were to treat what we saw as real. We were to observe the victim, assess the type and severity of their injury, and using the tools we'd been practicing with, we needed to provide a life-saving intervention. The instructors would watch us, but they weren't there to answer questions. If we got sidetracked or caught up in a non-productive course of action, they'd give some suggestions, but they weren't there tell us what to do.
Without giving away any specifics, the volunteers were set up with realistic Halloween makeup-style injuries – up to and including spurting arterial bleeding. For me, it was a little hard to get into the full spirit of roleplaying, but this was a major learning experience. First off – I found it a lot harder to decide what was the most critical first step for the injury I saw, and pretty frequently skipped steps or totally overlooked the obvious first thing that needed done.
With some well-timed suggestions, I was able to recover from my poor beginnings, but for the two most serious injuries, I was not doing too hot on my own.
Some nice attention to detail really added to the tension of the simulation – simple things, like someone with arterial bleeding spurting out, looking me in the eye and weakly saying “Help me.” An injured young lady, half-lying in a pool of her own blood, whimpering in pain, then crying out as I tried to secure her wound. In fact, after one student finished his first simulation, I could see he was a bit rattled – a little nervous laughter, he was a little bit pale, and he seemed to be really distracted by the need to get the fake blood off his hands. It was after I finished my second scenario that I found myself really sidetracked by the need to get that blood off of me. All of these things really ramped up the stress level. And this was a real layer of stress inoculation – I was less rattled by each new simulation. And that was one of the most unique things about the course – the ability to test what we'd been practicing, in some elaborately realistic situations, make decisions and take action under pressure, and have the safety net of not having mistakes hurt anyone. I did some things right, but as Shaun stressed before we did the simulations, I learned more from my mistakes than from what I did right.
There was a lot more information that was touched on or covered more lightly than what I've mentioned – from CAB – Circulation, Airway, Breathing, to the signs and treatments for shock; safety precautions like eye protection, gloves and masks – lots to take in in one night.
The instructors circulated through the room during the hands-on portions to answer questions or correct students – Bill even played injured when I needed a partner to practice applying tourniquets.
I got a lot out of this class. If you've got interest in learning more than Red Cross Basic First Aid has to offer, but aren't ready to take the giant leap to becoming an EMT, this class has potentially life-saving skills you can get in one evening.
So....on to the MacGuyvered equipment they showed in the class:
Digging around with the search function, I found this thread from 2009:
http://forums.equipped.org/ubbthreads.php?ubb=showflat&Number=181955&page=1which explores the idea of being prepared for a mass casualty event – a multi-car accident, etc. This class provided what I think was a great segue to preparing to help in such an incident.
When discussing equipment, Shaun told about a friend of his who was one of the first responders on scene at the Virginia Tech shooting. Shaun said his friend, an EMT, had his normal truckload of gear, but quickly went through all of it, because so many people were so gravely wounded. Apparently, most ambulances only carry a couple or a handful of commercial tourniquets. On the fly, he was using the common triangular bandages you know from Boy Scouts and first aid kits as a tourniquet.
That in itself is not too unusual, but he had an intersting twist on it that he now uses to equip his ambulance with a stash of cheap tourniquets to supplement the supply of commercial ones his ambulance carries.
Here's how he does it: holding the two long ends of the triangle, he rolls/winds it until it was like a thick cord (or one of those refrigerated crescent rolls you can cook in the oven)– that's a pretty standard tourniquet. The thing I thought was a nifty addition was he then slid a ring over it into the middle (Shaun said he prefers the orange plastic ring left behind when you remove the lid from a 32-oz bottle of Gatorade – he collects them. He said the rings from milk jugs aren't strong enough for this application. But in the MacGuyver spirit, he left open that there are lots of possibilities to replace Gatorade rings. Bill thought the pull rings from grenades would be perfect, because they're solid metal. I don't have a lot of those lying around, but I thought keychain rings could be good – WalMart sells a bag of various-sized ones).
So, with this setup, you lay the center/thickest portion of the tourniquet across the limb you're going to use it on, as high on the arm or leg (close to the armpit or groin) as you can get it, then tie an overhand knot underneath, then tie a second overhand knot onto the first knot – making the whole tourniquet snug, but it doesn't have to be super tight yet. Then, use a length of roughly thumb-thick dowel (about 6 or 8 inches long or so) as a windlass (another thing that can be improvised is your windlass. If you haven't got precut dowels with your tourniquets, Shaun suggested something like a closed pocket knife or Leatherman tool. He said a single pen would not be strong enough, but a handful of pens could probably do the job...or a wrench or screwdriver out of a toolbox or junk drawer. Again – this is something you can MacGuyver).
Slide the windlass in under the “top” of the tourniquet, then twist it tighter and tighter until the bleeding stops. Slide the ring over one end of the windlass to keep it from unwinding, then use the long, loose ends of the triangular bandage remaining from the bottom of the tourniquet to wrap over the windlass and tie it securely, and/or tape it in place so it isn't dislodged and loosened.
So, this is one way you could provision yourself with 10 or a dozen tournquets for around $25. He buys a length of dowel rod, gathers the Gatorade rings, gets his triangular bandages. He rolls the bandages, slides on the ring, and gathers/wraps up the tournquets so they store conveniently and can easily be unwrapped/extended for use, and stores them with a supply of dowel windlasses. Perfect to add into a mass casualty bag like the one from the 2009 ETS post.
I thought this was a great improvisation. One thing that Shaun and Joe both emphasized is that an improvised tourniquet SHOULD NOT be based on shoelaces, or 550/parachute cord, or anything with a narrow diameter like those examples. Narrow items like that could and very likely would cause permanent damage to the limb – so that type of material would only be used in the gravest situation, where there's nothing else that could be used, and where the trade of a limb for the life looks like the only option.
Another improvised substitution is the poor man's compression bandage. It's a plain maxi pad and an elastic bandage – preferably a wide one, 4 or 6 inches wide. Remove the adhesive backing from the maxi pad, attach it near one end of the elastic bandage (take a look at a commercial compression bandage to get an idea of how far from the end) and be sure that as you fold/wrap it up, you don't leave the pad exposed, and you arrange it so once you place the pad on a wound, you can simply unroll the remainder of the elastic bandage as you wrap it around the wound site.
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