Medical questions

[Nomad_Medic]

Hey crew. I’ve been watching the ‘talk’ and touching in with the guys on the medical refresher training that the chapter is putting together and it has gotten me to wondering a couple things.

First, what sort of training/experience does everyone have on the medical side of things?

(Red Cross First Aid-helped at a car wreck once, Pediatric Cardiothoracic Microvascular surgeon- saving lives daily and making big bank, Boy Scout First Aid Merit Badge- evacuated a kid with a broken ankle, Military Medic with multiple missions outside the wire in the Sandbox, etcetera.)

Second, what do people want to learn after they have a STRONG handle on the foundations of First Aid?

(Wound care and closure, Improvised equipment, Surgical Airways, Antibiotic Therapy, Ditch Dentistry, non-surgical GI complaints, etcetera.)

And finally, would there be any interest in me putting up posts about some of these technique/conditions in the Chapter Forum? I am not real interested in going ‘global’ (i.e. in the Medical Forum on the main site).

For the record, I am NOT a Physician. I have seen a patient or two and done a thing or two. You can see who I am in the intro thread.

http://www.survivalblog.com/2010/09/dealing_with_diarrhoeal_diseas.html <---That is a piece I wrote that Survival Blog picked up (and that one me first place in there writing contest) last year; what I put up here probably won’t be as ‘refined’ (READ “Shorter and less PC”).

Is the interest here?
NM
P.S. How the hell do I hyperlink text and not look like a moron show the text, not the URL?

[DropZedFred]

OK, I'll start since everyone else seems shy
Red Cross First Aid (20 years ago)
American Heart Association CPR Instructor Trainer (10 yrs lapsed)
US Navy Self Aid, First Aid, Stretcher Bearer, Decontamination Team
American Red Cross Orientation, Mass Care
DHS/CERT (VERY Basic)

Want: Army Combat Medic (i.e.: 68 Whiskey) - but more with a civilian feel, but still want to deal with GSWs.
My "thing" (you know, that nagging, gnawing "thing" that makes your brain twist and your stomach get all knotty?) is the "Active Shooter Scenario". I want to be able to put holes in the bad guy(s) and patch holes in the victims. Ideally.

Congrats on the SurvivalBlog win - I was published by Senor "JWR" twice before on automotive topics. Great source for TEOTWAWKI specific stuff.

Interest is here...

Hyperlink:
Type the word you want for the link.
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In use: Check out this thread for Medical Questions
Enjoy!

[MEANTREE]

Similar to DZF's desires, I want to be able to handle a situation where I am going to end a very real threat and have to immediately turn my attention to someone innocent that has been wounded by the "bad guy". My horrible scenario is a shooter in prowler form. Someone breaks into my place and I am not able to respond before they get a shot into my wife or myself and then I respond in kind to end the conflict only to have to immediately turn my attention to the wounded. I need to be able to patch myself or my wife up long enough for emergency services to show. Where I live is not as remote as some in the chapter. However, the response time on a GSW could be too long without a good immediate care.

I think learning how to stop arterial bleeding and staving off profusion would be my first choice of topics.

[Mall Ninja]

I've had the Mountaineers' Mountaineering Oriented First Aid (MOFA) (>10 years ago) - which consisted of Red Cross first aid plus a bunch of stuff on how to deal with injures common in climbing and what not - but what little I haven't forgotten I know to be horribly obsolete (ie CPR).

Like the others, and as I've mentioned before I'm also interested in learning how to deal with GSWs - right now the contents of my IFAK are more in the hope that if something bad happened to me, there would be somebody nearby who knew how to use them - I think I could manage a compression bandage or a CAT, but I wouldnt want to try an NPA or a decomp needle or even the Celox...

The other thing I'm interested in is SHTF first aid - ie we get that big subduction quake and even if the hospitals are still standing, communications and the roads are mess and instead of the ambulance/EMTs being less than 15 minutes away, they're 15 hours or more away.

I've been fortunate in that I never been in a situation where I or anyone else nearby has needed anything more serious than a bandaid, but I figure sooner or later karma is going to catch up to me...

[marktaff]

Experience:

Basic first aid: BSA circa 1980
Self-Aid & Buddy Aid (inc. NBC): US Army BCT circa 1990

I'm interested in moving from basic first aid closer to paramedic skill levels. Scenarios include GSW, serious injury hours or days away from paramedics, and mass casualties due to the inevitable Cascadia quake. That quake is going to happen at some point, and I'd like to be ready for it in case it happens while I'm still alive.

Of particular interest in the mass casualty scenario is triage.

[Nomad_Medic]

Alright folks, let me get started.

I had a big disclaimer typed out that this internet post doesn’t teach you enough to do much and that anything you do is on you and yada, yada, yada. This is the internet, I’m just some guy (I could be a some lock-in blogger from Jersey for all you know), use your melon, this is medicine. That means it’s not only somebody’s life, the lawyers circle like vultures. Nuff said?

A little perspective first, shall we? While I applaud those that desire advanced medical training, (Paramedic, Military Medic), understand what is involved in these fields; there are no ‘hobbyist’ here. Even attending all the training to get to these levels just makes you someone with an alphabet after your name. To be competent at these levels, you MUST have experience. Until then, you’re still a student. That’s a tough lesson for baby ‘medics and often one that is painful. It’s rough having a dead kid crush your self-image.

That being said, you can get a decent start without dedicating yourself to a full time healthcare job. The basic knowledge of how the human system works, a general idea of what happens when there are problems with that system, and the basic skills to relieve those problems, form a foundation that all medical disciplines can fall back on. I have said many times that I would choose a strong EMT-Basic over a weak Paramedic to work on me or mine.

The #1 most important thing that anyone, regardless if they are Bubba the bus driver stopping at a wreck of Chief of Surgery at Johns-Hopkins, needs to know is "Know what you DON’T know". Keep that in mind and you’ll be okay.

The other most important things is “Primum non nocere” or "First, do no harm" That’s pretty self explanatory but people forget it waaaay to often.

Enough preamble? Well, I’m not quite done yet. It seems like people want to talk GSWs and that’s fine. This is ZS though so let’s start with the…Carebear scenario of someone getting shot. I’ll touch briefly on the whole ‘Active Shooter’ consideration but I am still a student on the tactical side. (Running around with a gun doing scenarios and having fake blood squirt on me make-ith me a tac medic not). So for today, let’s assume that ‘The System’ is still intact and help is on the way. Our casualty/victim/patient (Pt) will take a round at say, the local National Forest Range. We will concern ourselves with keeping them alive until they are turned over to ‘The Professionals’. (I do tend to get on tangents so who knows just what will creep in here?) I am going to focus on treatments that you can perform and be covered under the Good Samaritan Laws. Maybe later we’ll change this focus.

Oh, and my satellite signal is intermittent at best (typing in word for later posting) so I may not get links in for references of examples. Exercise your Google-Fu. Having said that, a couple ‘books’ I will be digging through and probably referencing are “75th Ranger Regiment Ranger Medic Handbook 2007”, “Emergency War Surgery 2004” and I am sure a few more. Also be sure to check out the NAEMT TCCC website. Downloading the PowerPoints and videos will give you a bunch of information to work with. I would also HIGHLY suggest anyone interested in care after a GSW read the ‘Medic’s Lessons learned” paper on the same site. Why these? Mainly because they pretty much line out what we’re talking about and most importantly, they can all be downloaded for free and carried in my magic hard drive. Please keep in mind that none of these are really meant for the lay person but rather someone that has undertaken extensive training and already has that foundation I mentioned.

Air goes in and out, blood goes round and round, any deviation from above is bad. Class over, you know what you need to, Thank you and goodnight…..what, you want more? Well, okay then.

When we talk about evaluating and treating a Pt, we must always remember 1 thing “The most important person on the scene is me.” You’re safety is paramount; by the fact that you are ‘helping’ means there is already at least one casualty. Adding to the body count because you stepped into traffic or ran into the open to render aid and got zapped makes things worse. Every scene needs to be made safe before you initiate care. TCCC teaches the first step in treatment during the Care Under Fire Phase is “direct casualty to return fire and take cover” So step 1 is always ‘Ensure scene safety’

Next we move to the Primarily Survey. The Primary Survey determines Life Threats and we interrupt the initial Primary Survey ONLY to correct Life Threats. The Primary Survey is as follows and we will address each point individually.

C - Catastrophic Bleeding
A - Airway Maintenance and C-spine Stabilization (situation dependent)
B - Breathing
C - Circulation
D - Disability
E - Exposure/Environmental

But wait, you say. I was always taught the “ABC’s of First Aid’. Yup, we used to, same in CPR. But not anymore, because we found a better way. The main catalyst for the change regarding First Aid is that the majority of soldiers dying in combat operations over the last decade have been due to massive hemorrhage, bleeding that kills before a closed airway would. When it comes to CPR, it was because pumping early is more important than blowing early but that is a topic for another day. So let’s talk about what these each mean and how they relate to our bad-day-at-range patient. (See TCCC course materials, and “Highlights of the 2010 AHA Guidelines for CPR and ECC”)

The scene is safe and we approach out casualty. The Primary Survey begins as we walk up, in this case looking for massive bleeding. Now when we are talking about ‘Catastrophic’ we mean kill-em-quick bleeding. Oozing, seeping, and dark colored blood usually (there are VERY few ‘Always’ or ‘Never’s in medicine) are not going to produce this kind of bleeding. We are talking about squirting, flowing, and spraying blood. Not all arterial bleeding is catastrophic and just because it’s venous, it doesn’t mean it can’t kill-em-quick. BTW, who knows the difference between arteries and veins? You, in the back? Yes, the direction they carry blood, you get a cookie. Arteries carry oxygen rich blood away from the heart and are under much higher pressure. This is the bright red stuff that squirts when the heart beats. Veins carry the de-oxygenated blood back to the heart/lungs to the cycle over again. This is the low pressure side. When we look for this blood, we are doing a quick head to toe sweep for serious bleeding. Always remember Pts have more than one side; it is poor form to treat an entrance wound and have the casualty bleed out from an exit wound.

We check our casualty for catastrophic bleeding and low and behold, we find some! What now Batman? Duh, we stop it! Direct pressure, tourniquets, and hemostatic agents, can all be utilized to do this. But as it says in Emergency War Surgery “Direct pressure at site of injury is the most effective and preferred method of hemorrhage control… Hold pressure for at least 5 minutes before looking to see if it is effective.” Direct pressure very often is all it takes to control bleeding. To use this technique, not to be an ass here, apply pressure directly to the spot the blood is coming from. The best way is with a wad of gauze pressed hard into the wound, preferably with both hands. Once you have the bleeding controlled this way, you will most likely need some way to maintain the pressure. In my opinion, there is no use separating pressure dressing as a separate treatment; the bottom line is push on the wound to stop the bleeding. Tightly wrapping the area or using an ace wrap can sometimes do the trick. If not, someone may need to maintain pressure until the patient arrives in the OR.

If the bleeding cannot be controlled with direct pressure alone you can look to your hemostatic dressings, especially if the wound is not on an extremity. Combat Gauze is gauze that is impregnated with a substance to facilitate clotting. While it has been touted as pretty wiz-bang stuff, the studies aren’t that impressive when compared to direct pressure. Again, I’ll refer you to the NAEMT website with the process on video. But remember: it is imperative that you still apply direct pressure while using the homeostatic dressing.

Now in a hostile situation or catastrophic bleeding from an extremity you are better off skipping the dressing and dropping a tourniquet in place. For a lot of years, we taught that tourniquets were big bad medicine but guess what? We were wrong! TQ’s work, and well. 60% of preventable deaths in combat are due to bleeding out from and extremity. Get a CAT or SOFTT, they work better than anything you’ll be able to improvise. In the Bush without a commercial TQ, well then I guess you better improvise. A wide band made from a cravat or even a tee shirt with a handle tied into it to twist it tight can work. This is something to practice before hand. Anyway, about TQs. These work by crushing all the vessels closed and thus returning a closed system to a closed status. As such, they need to be applied in such a way as they can occlude (block off) the vessels. That means they need to be applied away from joints and should be put at least two inches above the wound. Place it as directed by the manufacturer and twist until the bleeding stops. Be sure to secure the Windlass/Handle well; if that comes undone it may very well kill the Pt. Once the TQ is in place, LEAVE IT IN PLACE! Pts have died because the ‘rescuer’ kept loosening the TQ to see if the bleeding had stopped or to reprofuse the limb. We also used to teach that a TQ guaranteed that the limb distal (farther from the heart) to the TQ was written off. That isn’t the case anymore and limbs have been saved after many, many, hours with TQ in place.

Emergency War Surgery talks about two other techniques for bleeding control. I am not a fan of either having seen little benefit from either one over the last 15+ years and both are a pain in the back side for the rescuers. I imagine it would be different if you were static or had more hands than you needed but I have not ever found myself in that position with a bleeder on my hands. As a matter of fact, I am usually trying to get outa Dodge with my Pts. These techniques are elevation and indirect pressure. Obviously, these would only be of use with extremity (arms/legs) injuries. Elevation is just that and can be done in conjunction with direct pressure. The wound is elevated above the level of the heart with the idea that gravity will be of some assistance. Now would probably be a good time to tell you that if your Pt has ‘Catastrophic Bleeding’, have them lay down. If makes you look bad if they get so hypovolemic (low blood) they pass out and crack their egg. Just get them down before hand. The other technique is indirect pressure, also called pressure points. The idea with this technique is that you occlude the major arteries to the effected limb by pressing on them, typically with your fingers. This is the same concept as a TQ but much more difficult to maintain. This is generally done to the femoral artery by applying pressure to the crease in the leg, and to the brachial artery by pushing on the inside of the upper arms. This is one of those show-not-tell things so fire up Google. As I said, these techniques probably work better if you are sitting in one spot but I have had little success with them.

This seems to have gotten pretty long winded and much more rambley than I had planned. I think I’ll call this good for today. Please ask about the points that I have been confusing on and share your thoughts. Does anyone here have any personal experience with a casualty that was bleeding profusely? What worked for them?

[marktaff]

Nice post, thanks.

[Nomad_Medic]

Shall we continue?

There is something I should have made clear in my previous post that I want to put out there right now. As I said before, there are few ALWAYS/NEVER situations in medicine. But in the case of the CABCs, there is. The CABCs are in the order they are, and have to be ‘fixed’ in that order, for a reason. They are prioritized by how quickly they make your Pt dead and if you do not ensure they are intact/patent, the Pt will ALWAYS die. For that reason, we don’t move from catastrophic bleeding until we have it controlled. After that, we MUST have an airway before we work on breathing; get the idea?

Now onto the next ‘lesson’ (and I use that term loosely).

We’ve talked about the first two things that need to be evaluated and dealt with on every Pt:

Is the scene safe?
C – Catastrophic Bleeding

Next up is A – Airway (and C-spine; I’ll talk about this in a bit). It’s hard to separate airway and breathing but we need to. When we say ‘Airway’ what we are talking about is a pipe or path for the air to get in. So when we evaluate the airway, we are asking CAN the air get in. For our purposes, the airway starts at the face with openings at/structures in, the mouth and nose. These continue down the throat, and pretty much stop at the level of the clavicles (collar bones). No, that is not all of the airway but as far as we’re concerned, that’ll do.

As I said, right now we are concerned with can the air get in which translates to “Are any/all of these pathways blocked?” Anyone know what the most common thing is to block the airway of the unconscious adult? Anyone? Anyone? Bueller? The answer is the human tongue. If you downloaded the TCCC PowerPoints I already mentioned, look at the ‘Tactical Field Care’ presentation, slide 18. That gives you a basic idea of what I am talking about. Google ‘adult airway tongue’ and you’ll get a few images showing why the next technique works to move the tongue. But before we get to that, what can block an airway? If you answered ‘Just about anything.’ you’re right. Food, teeth, blood, displaced tissue (i.e. GSW to the face), swollen tissue, toys, rocks, you get the idea, right?

When we look to see if the air can get in and out of the conscious casualty, it’s pretty easy. If they are talking to you, the airway is patent at that moment. Screaming, swearing, and bitch’n counts too. If they are clutching their neck, turning blue, attempting to breath without moving anything in and out, the airway is blocked. The thing about airways (and breathing too) is that in the Big Sick Pts, they can and frequently will, change quickly. Of course, they rarely get better so you know what that means. Now with your conscious Pts, this change is usually accompanied by a change in how awake we are. That is the ‘D’ part so we’ll hold off on talking about that for a bit. But people that have be hit in the throat, inhaled hot air/gas, or are having a significant allergic reaction can lose an airway and remain conscious. Keep a close eye on anyone that has had an insult to that narrow pipe that goes from the head to the lungs.

Staying with a conscious casualty, let’s talk about how to fix a blocked airway. In that dude that was sucking down a burger and is now clutching his throat and turning blue, we use the Heimlich maneuver. I can’t from here but I am sure YouTube can show you the basic idea. Really though, everyone should take a CPR class were they teach clearing the airway of a conscious and unconscious victim. In the guy that taste tested the 12 gauge or the famous moron that has appeared in EMS textbooks since the 70’s after trying to crimp a blasting cap with his teeth, the face and airway can be dam near unrecognizable. Take a look at slide 20 in the same PowerPoint I mentioned a little bit ago. With significant facial trauma, bleeding can be a huge airway problem. The head is very vascular (lots of vessels) and while this bleeding can fall into the catastrophic category, it usually doesn’t. If the Pt is conscious, they will be doing whatever they can to get in a position that they can get air. Your job in this case is to let them. Do what you can to keep the air hole (usually the one blowing bubbles) clear. Use gravity to your advantage. In some unconscious ‘gooey’ casualties, turning them so they drain away from their airway will keep them alive. The point is make sure the airway works to let air in and out.

Most trainings focus on the unconscious Pt because these people are in real danger of occluding (blocking) their airway and dying. We teach two techniques for opening the airway in an unconscious Pt; the chin lift (sometime taught with a head tilt) and the jaw thrust. Again, Google and YouTube will give you the idea for both of these but that CPR class you are going to schedule when you finish reading this (hinty, hinty, winky, winky) will teach you how and allow you to practice. There are a couple differences between the two. The first one is the indication. The jaw thrust moves the neck less than a chin lift. This technique is used when a neck injury is suspected (i.e. mechanism conducive with the melon going all bobble-head, unconscious after a fall, significant acceleration/deceleration incident, ect.). The other major difference is that a jaw thrust is a real pain in the keaster to do well or hold for long. If you cannot get a good airway with the jaw thrust, go to a chin lift. Remember, no airway=DEAD so opening that tube has priority over a neck injury.

{Tangent: I am a CPR instructor as is Doc Bunny. He lives up near most of the chapter and has access to training equipment (neither of which I do) so maybe we can/should setup a class. Keep in mind that a certification class will get you a card that shows you’re not just cowboying your treatment and only costs a few bucks.}

Now this is the part of treatment where Nasal Pharyngeal Airways (Nose Hose, NPA, Nasal Trumpet) come in. These are a tube that goes in the nose, across the floor of the nasal cavity, and into the back of the throat. I am going to tell you that I don’t think anyone should be using these in the scenarios we have been talking about. For one, you really need hands on training to know what you are doing with these. While the chances are low, you can stick this into the brain, a situation that doesn’t help the casualty. You can make the victim puke which presents the potential for a huge airway problem, and unless you are doing this professionally, you’re probably acting above the scope of your training/practicing medicine without a license. And, most importantly, you can do the same thing with good airway maneuvers with a lot less risk.

Another thing that comes up here is a Cricothyrotomy (Cric). This is an advanced procedure from every way you look at it. If you cut in the wrong spot, too wide, or too deep, you still have no patent airway. Don’t do this unless the world has ended and even then, know the Pt may still die. The TCCC site has videos on this procedure and in all honesty, one you get past the fact you are cutting your Pt’s throat, they are not that tough.

Keep in mind that the legalities of simply carrying certain medical products can get you into trouble. Is that needle part of a First Aid Kit or is it drug paraphernalia? Is it stamped ‘For use under the care of a physician only’? What happens if you get a dirty stick and catch something? What if you try putting an NPA into someone with a skull fracture and they end up vegetative? If you are not trained and backed by someone licensed, maybe you shouldn’t be carrying it.

What airway issues did we miss on our day-at-the-range casualty? If they are conscious and have a mechanical disruption of the airway, keep the pipe clear through positioning. One thing we didn’t touch on was sticking your paw into somebody’s mouth. A. Remember scene safety and keeping yourself safe; don’t get your fingers bit off. B. Don’t reach in there unless you see something. The airway gets narrower back there behind the tongue. If you shove that obstruction into the narrow part, the Pt can well and truly be hosed. If our guys got popped in the gord, he’s probably unconscious so use the airway maneuvers as above. And put that frigg’n knife away, NO throat cutting! We good on the airway stuff?

I also said that C-Spine gets lumped into the ‘A’ so I will talk about that as well. As I mentioned above during the whole chin lift/jaw thrust thing, we need to keep an eye out for potential injuries to the Cervical Spine (the C spine is the top 7 vertebrae or spine bones. The top two are darn near buried in the skull and the bottom one is that sticky-out one just about where the collar of your tee shirt is.) This is kinda the weak link in the spinal column. Our heads are relatively heavy and get tossed around a fair bit during traumatic events. As such, we need to look at how someone was injured (Mechanism of injury) and decide if the potential for a neck/spine injury is there. When we get farther into our exam we will check some specifics but for now treat on mechanism. Some mechanisms that should make you suspect a potential C-Spine injury include (quoted from the Ranger Medic text listed previously, the bracket translations are mine) “…blunt head or maxillofacial {Facial}trauma and/or mechanism of injury (static-line or freefall jump incident, fastrope or rappelling incident, aircraft mishap, motor vehicle collision, blast injury, fall > 20 feet)… Cervical spine tenderness to palpation {pushing on} and spasm of the musculature of the neck can be associated with a cervical spine injury.” If any of these exist, initially treat the Pt as if they have a neck injury. Like I said we will talk more about this, and when you can say, ‘Eh, I don’t think his neck is busted.’ later on.

Now you’re guy at the range didn’t get shot but some moron raced into the parking lot at 30mph, spun a donut, and clipped your Pt. Getting hit by a truck=mechanism of injury consistent with a C-Spine injury. What do you do? The scene is safe (moron ran like hell) and you find no catastrophic bleeding. The C-Spine portion here means as you/your help come up to the Pt, you ‘assume manual cervical spine control’. That is a fancy way to say you grab the guy’s head to keep it from flopping around. Right now you are sitting in front of a screen reading my drivel. If you are sitting squared off to the screen, head perpendicular to the floor looking straight ahead, your head is in a neutral, inline position. This is how we want to keep our casualties head. If we find him on his back, or even if he gets up and you meet him sitting at a bench, this is how we want him to be. If he is not, we need to GENTLY bring his head to this position. If you meet resistance (i.e. need to brace to turn his head), cause pain (see that Latin expression from my earlier post), or the victim is not cooperative (Some head injury patients will fight; same with folks that have had a seizure), stop what you are doing. In the first two cases, stabilize the head in the position you found it, in the later try to calm the patient but holding the head of someone fighting you can cause a neck injury. Once we have assumed manual stabilization that set of hands is locked up. They cannot let go until someone with great malpractice insurance tells them to let go, the casualty is fully immobilized, continuing presents a hazard to the casualty of rescuer, or you are confident there is no injury. Again, we’ll talk more about clearing C-Spines in the field later.

I think I have hit the high points. We know that we watch out for ourselves and make sure the scene is safe before we initiate treatment. We know to check for and treat catastrophic bleeding, assume C-Spine control, and check for an airway. We’ve discussed how to open an airway. What questions are there now?

[Nomad_Medic]

More will follow, just home from work now so I have a life....even if this thread seems to be me talking to myself

[MEANTREE]

Definitely not talking to yourself. There are at least two people listening (if you count the voice in my head). Keep up the good work.

[pasha]

Definitely not talking to yourself. There are at least two people listening (if you count the voice in my head). Keep up the good work.

^ This, thanks for the great info.b d

[DropZedFred]

Ditto, just taking it all in...
Drinking from the ZS "fire hose of knowledge".

[JustInCase]

If feed back is desired, I suggest writing in smaller blocks of info. Just my adjusted for inflation $0.02.

[Nomad_Medic]

Hi kids, miss me? Sorry for the delay (just being lazy and haven’t written anything, really need to put in some time on Mechanical Issues), but let’s get back at it.

I am glad that folks are reading this and JIC, thanks for the feedback. Unfortunately, I’m pretty much gonna ignore it, nothing personal. While I could probably gab less, I probably won’t and breaking things into the CABC’s just makes sense.

So what did we talk about already? Feel free to review but the Readers Digest version is the Primary Survey. So far that has been…

Scene Safety
C - Catastrophic Bleeding
A - Airway Maintenance and C-spine Stabilization

Up next is Breathing. Just as ‘Airway’ means questioning if air CAN get in and out, ‘Breathing’ asks IS air getting in and out. It really seems like the same question and they get lumped together in practice, but they are separate questions.

When we concern ourselves with the structures of breathing, we need to include all the airway parts and throw in an ‘intact chest wall’. Another part that is important (at the first aid level) when we talk about how people breathe is the diaphragm. So how do these parts work together; pretty simply actually. When we inhale, the muscles of the chest wall tighten up, causing the chest to lift up and out. At the same time the big, smooth, flat, muscle that separates the chest cavity from the abdominal cavity, the diaphragm, tightens up and drops down. These actions create a negative inter-thoracic (inside the chest) pressure and thus draw air into the lungs via the airway. Do a Google Image search for ‘breathing anatomy’ and you’ll get a bunch of pictures that show all this clearly. When we exhale, all these muscles relax and things drop back in place. As such, you can think of inhalation as an active operation, and exhalation as a passive one (this is important for later).

So how do we check breathing? I just touched on this in airway and should have fleshed that out more but, well, oops. Again, checking airway and breathing go hand in hand.

In the conscious Pt, we will usually pick up on breathing issues fairly quickly. Nobody (this might change after the Zombie Apocalypse) walks into a room and thinks, “Hey, that guy is breathing!” Why? Because normal breathing isn’t something we notice. If you notice someone’s breathing, especially if they are sick or injured, you need to ask yourself WHY you noticed it. Is it too fast, slow, shallow, labored, noisy? Adults normally breathe with little work of respiration at 12-20 times a minute. A lot of things, from anxiety to injury, can change that rate. In the Primary Survey though, we are looking for life threats. As such as we check breathing, we are mainly looking and listening for conditions that will make people dead. In the conscious Pt, life threatening breathing is associated with people working to breath and is pretty obvious most of the time, just like the presence of the open airway.

The unconscious Pt is where the old ‘Look, Listen, and Feel’ comes in. This is where we are getting our face down in close to the Pt’s mouth and looking towards their toes. We are looking for rise and fall of the chest, listening for air moving in and out, and feeling for breath on our ear.

If our Pt isn’t breathing, then what? In case you didn’t know, not breathing is not consistent with living a long, happy life. That being the case, we need to breathe for our Pt. There are a few different ways to do this but at the first aid level, really only one good one. YOU can lock lips with the casualty, I won’t. (Except my wife and kids.) This is kinda in violation of that most important person rule I mentioned before. Mouth-to-Mouth puts you at significant risk of eating what they ate because if you are blowing into someone else without an advanced airway, they will puke. No, really, gonna happen, pretty much one of those ‘always’ things. The goal then is to not get that goo in your mouth. We do this by using a barrier device, preferably a mask with a one way valve. These are relatively easy to use, cheap, and available so I am a strong believer that ALL first aid kits (beyond a blowout kit) should have one. Again, I cannot look at videos from the boat but I am sure youtube can show you the proper technique for using a pocket mask. We want to hold the airway open and provide slow (over about a second) breath in, watching the chest rise. When the chest stops rising, stop blowing. Any extra you put in is headed for the stomach to collect everything there and then come back to visit like a bad case of the crabs. How often do we breathe for the Pt? Look up….not at the ceiling genius; look at the paragraph before this one. Right, 12 to 20 times. But we are gonna shoot for 12 for a couple reasons. First, that way YOU don’t hyperventilate and pass out; second you’re adrenalin is going to be flowing so you’ll probably be moving like a squirrel on meth so you be giving more than you think you are, and finally because the math is easy. Every 5 seconds you give them a breath. Easy peezy, right?

I have a bunch more typed out that I am going to review and post in the next few days. I know I said I wasn’t gonna break this up but…I changed my mind. The next section will cover some of the more advanced breathing points as they are fairly complex.

Questions?

[Nomad_Medic]

The last post was the real basic part of breathing; let’s touch on a couple things that are a little more involved. What I mentioned before is what you are taught in most First Aider courses. If you look at the Ranger Medic’s handbook, the breathing section of the Primary Survey doesn’t mention any of the above. Why; because the Medic has already been trained in all that at the most basic level. But this is ZS and you want MOAR, right?

This is what the Ranger medic’s handbook says on the subject of breathing in the PS.
“B. BREATHING The patient’s chest should be exposed and you should look for symmetrical movement of the chest wall. Conditions that often compromise ventilation include: MASSIVE HEMOTHORAX, TENSION PNEUMOTHORAX, OPEN PNEUMOTHORAX, and FLAIL CHEST.”

Keep in mind that this is written for the trauma Pt. While you CAN develop some (okay, realistically 1 or 2 if you hold your brain just right) of these conditions medically/spontaneously, they are most likely due to significant blunt force (thump) or penetrating (poked) chest trauma.

We look for symmetrical (equal on both sides) rise and fall of the chest to make sure things aint broke. What things could I be talking about? Oh, come on, this is an easy one! Yes! The ribs! Like I mentioned when I was talking about the anatomy involved with breathing, the chest wall should move as one piece. If you have three or more ribs broken in two or more places you have what is known as a flail chest. This injured area tends to do its own thing when the Pt breaths, specifically, it moves paradoxically (opposite) to the rest of the chest wall (i.e. it moves out when everything else moves in). This is bad for a couple reasons. For one, it hurts. And this isn’t like ‘Oh whah, here’s a straw, suck it up.” hurts, this can hurt so much people won’t breath. Most schools of thought still teach that it is best to stabilize the flail segment. This is best done with bulky dressings and lots of tape over the top of it to help it move with the rest of the chest wall. DO NOT go old school and put a sandbag on it; this restricts chest movement and is overall bad for the Pt. Pain control is needed here but that is waaaaay above First Aid level. Another concern with a flail chest comes from the fact to takes a lot of force to bust someone up this way. That force probably didn’t all dissipate on impact with the ribs so we need to think about what other structures were damaged. When we expose the chest, we are also looking for the very fancy sounding ‘Open pneumothorax’ AKA a sucking chest wound. We’ll talk about that in a minute, for now a little medical terminology and more anatomy is needed.

I think most people know that thorax means the part of the body between the neck and the diaphragm. ‘Pneumo’ means air and ‘Hemo’ means blood. So a pneumothorax literally means air in the thorax and hemothorax is blood in the thorax. That’s the terminology part; now for the more anatomy part.

A pneumothorax or a hemothorax develops in a space that is, kinda theoretical and known as the plural space. I know that doesn’t make a lot of sense and the diagrams in the TCCC PowerPoint ‘Tactical Field Care’ slides 42 and 43 should help but I am a bit redneck so I explain it this way: You have a jar and you put a deflated balloon into it. Then you blow that balloon up so it fills up the jar, conforming to the shape of the jar. If the jar is the chest wall, and the balloon is a lung, the space BETWEEN them is where a hemo/pneumo thorax will develop. Normally, that space really doesn’t exist. But if something, say a blast wave from an IED, tears the lung then air or blood can get into that theoretical space. Air or blood in the plural space is the definition of a pneumothorax or hemothorax respectively. A Tension Pneumothorax is when the amount of air becomes so much that it squashes the lung. This is BAD, like kill’m quick Kemosabi bad. Per TCCC, tension pneumos account for 5% of ground combat death in Viet Nam between ’67 and ’69. This really is a killer.

Where was I, oh yeah, Tension Pneumothorax? This develops over time as more air seeps into the plural space. As the plural cavity is filled, the lung and then the heart are compressed. This kills the patient. The biggest clues we need to watch for are mechanism (penetrating trauma to the chest, blast waves, blunt force to the chest), difficulty breathing, and the most definitive yet also kinda beyond first aid, absent breath sounds on one side (it can happen bilaterally; that is the definition of a bad day.) Look at Tactical Field Care’ slides 43 for the full list though a lot of those (tracheal shifting, distended neck veins) are pretty far into the FTD (fix’n to die) realm. This is why people are always going on about a chest dart…er, a needle chest decompression kit. The treatment for a Tension Pneumo is to relieve the pressure. We do that by sticking a whack’n big needle (preferably an IV catheter since they are a needle with a plastic tube over the top; once it is place, the needle comes out and the tube stays) into that plural space letting the air out. Slides 46-48 of the presentation listed above show some pretty important points on this skill. The needle can go in a couple different places but TCCC teaches anterior (front) chest, mid-clavicular (in line with the middle of the collar bone), between the 2nd and 3rd ribs. To insert, we find our site, try to cleans the site (don’t waste a lot of time), and take our trusty needle and insert it by holding it perpendicular to the chest wall and pressing it in. We need to avoid the nerve/artery/vein cluster along the bottom of each rib and to do this I was taught and have always used a Z-tract technique. You insert the needle a little lower than the space between the two ribs and press in until you hit the bone. At that point you pull back SLIGHTLY, angle up, and scrap over the top of the rib. Once you hit the top, you return to that perpendicular angle and drive on. You should feel a pop as you enter the plural space and when you remove the needle, you will get a rush of air. Different schools of thought teach s couple minor points of difference but that is the basic idea. A lot of people will attach a syringe to the needle before they enter and draw back slightly as they advance so they KNOW they are in. One thing I have done that you won’t see in any texts is to knick the skin at the insertion site after I cleaned it because skin can be really tough and driving that nail through the chest can be tough. The Ranger Medic’s Handbook has a flow chart on this technique and I am sure Google can give you a few more demonstrations.

So, now we have harpooned the Pt but they aren’t fixed yet. We have converted a Tension Pneumothorax to an Open Pneumothorax. To prevent this from collapsing the lung (floppy collapse, not tension collapse) we want to put on a one way valve. You can do it with the finger of a glove, a tube and a bottle of water or best of all, with a commercial one like an Asherman’s Chest Seal. Now the air can escape the chest but not flow back in. YOU MUST WATCH THIS PT CLOSELY! If that tiny little hole get blocked by say, I don’t know, a blood clot, you can be right back at square one with a Tension Pneumo. That means you dart them again.

When we expose that chest, we are also looking for Open Pneumothorax or Sucking Chest Wounds. This is that gunshot wound to the chest people are always worrying about. Remember when I said “Air in and out, blood goes round and round, any deviation from above is bad.”? Well, a SCW kinda screws both of them up though we are mainly worried about the air part. To treat a hole in the chest we, I know it sounds crazy but stay with me, we cover the hole. I know, wild huh? Now us old school Medic’s had the three sided dressing (works like a big one way valve pounded into our heads but they really are not necessary and an occlusive (airtight) dressing is less of a pain to apply and works just as well. You can use a proper dressing (i.e. Hyfin seal) for this or improvise one from the plastic you bandages come wrapped in. I have a close friend that makes his living at this and he always carries a roll of saran wrap in his kit and can patch a chest with 3-4 holes faster than a lot of people can do one. The important part is to keep the air from moving through the chest wall. But, like above, you have to watch these Pts closely for signs of a Tension or they will die on you. There are some videos on this on the NAEMT TCCC website.

Now the last point I will touch on briefly (and only because the Ranger Medic’s Handbook brought it up) is the Massive Hemothorax. Massive in this case is defined as over a liter and we already mentions hemothorax means blood in the chest. In the field at this level, we are not going to do anything to relieve this. I will tell you this condition is relieved by a chest tube but I am not going to get into how to do one but there is a flow chart in the Ranger Medic’s handbook. This is a very invasive procedure that can god wrong in a whole lot of ways and without proper continued care can kill your Pt. Feel free to dig for more info and I will answer questions but that is as far as I am going here.

We are out in our favorite National Forest popping off rounds with the brother-in-law. Now, said BIL ate a lot of paint chips as a kid so he’s not the sharpest tool in the shed. Doing his best Wyatt Erp impression, he twirls his cocked Single Six around his finger and pops off a .22 LR into his lower right chest. Despite you’re burning desire to let this be the drop of chlorine the gene pool is in desperate need of, you step in to help.

First step, ensure your safety. In this case, (because he’s proven he’s a moron) that means disarming the Pt and making sure the range is clear and you slapping on a pair of gloves. (As TCCC discusses through the course, an injury doesn’t not automatically take the Pt out of the fight UNLESS they have an altered level of consciousness.) Next is Catastrophic bleeding, there isn’t any. As numpty falls to his butt, you can see a small blossom of blood appear on the front of his shirt. A quick look finds no exit would or any other sources of bleeding. Airway- Pt is crying like a 6 year old and screaming “I got shot!” so you know he can get air in and out. This also tells you that he is breathing. You’re squared away but money is tight so you don’t have any fancy, purpose built, occlusive dressings in your blowout kit. But your field dressing comes in a plastic wrapper so you open it and use your Leatherman to cut it so you have a flat piece of plastic. When your Pt exhales, (when there is the least amount of air in the chest) you slap the sterile side of the plastic over the wound and tell Bobo to hold it in place. While he holds it, you tape all 4 sides down. You finish your PS (More on this later) and your think he’s okay to be left for a minute while you call for help. You have him lay down on his coat, cover him with your jacket, and walk (Heroes dash. We don’t dash unless our lives are in threat. Dashing on a scene violates the premise of keeping yourself safe first. Always walk/move in a safe manner.) to your truck where you get on the CB net and call for help. After a couple minutes, you are assured that help is on the way and you go back to your Pt. You find him sitting up, struggling to breath and looking panicky. His skin is pale and his lips have a slightly blue tinge. (We’ll get detailed about the thinking behind the next couple steps later.) You repeat your PS and find no significant bleeding, a good airway, but obviously his breathing isn’t getting the job done. Remembering your training, you quickly open one side of the dressing and get a rush of air. His breathing slows and his color improves. He refuses to lay flat and you are okay with that as you know that allowing him to find the position he can breathe in is more important than his laying flat.

Okay, so that was a big dump of info but what are the questions? I see the ‘viewed’ count going up and I know I’m not THAT good, what is still confusing?

[KJ4VOV]

Experience:

14 years in NYC as an EMT (1985-1999), ACLS certified

[Nomad_Medic]

Okay, I have it figured out! I was totally confused as to why KJ4VOV was posting and introing himself here......Bernie, you clicked on the wrong chapter; ZSC:006 is next door.

Not that you're not welcome to come play, I just imagine you won't be making the commute from VA to WA for too many chapter meeting. Hell, it's only a couple hour drive for me and I haven't made one yet...

Anywho, more medical crap will follow...eventually...no, really...

[KJ4VOV]

Okay, I have it figured out! I was totally confused as to why KJ4VOV was posting and introing himself here......Bernie, you clicked on the wrong chapter; ZSC:006 is next door.

Not that you're not welcome to come play, I just imagine you won't be making the commute from VA to WA for too many chapter meeting. Hell, it's only a couple hour drive for me and I haven't made one yet...

Anywho, more medical crap will follow...eventually...no, really...

Nope, I clicked the right one. My wife is from Lewiston, ID, she's a Duck, and her dad & one of her brothers live in Clarkston, WA. We go out there fairly regularly. In fact, we'll be out that way next week, since we're flying to Monterey, CA on Sunday, attending the wife's graduation ceremony from the Naval Postgraduate School there, then doing a bit of driving to visit family in Washington, Oregon and Idaho.

[Nomad_Medic]

Ahh, the lack of questions either means I am being really clear, nobody gives a rat’s rear, or I am talking to myself. Oh well, I’ll keep going anyway I guess.

We’ve already talked about making sure the scene is safe and have started working through the Primary Survey. So far, that includes:

C - Catastrophic Bleeding
A - Airway Maintenance and C-spine Stabilization (situation dependent)
B – Breathing

So yeah, next up is the second ‘C’ as in circulation. At the First Aid level, this is kinda a yes/no thing but we’ll get into it a little more than that.

As I mentioned in one of my early posts, air goes in and out, blood goes round and round, any deviation from above is bad. We’ve really covered the air part but just touched on the blood side of things. That is where circulation comes in.

When we talk about circulation, we will talk about some anatomy we have already touched on in the Catastrophic Bleeding portion. There we were talking about the plumbing part of the Circulatory System; here we are mostly concerned with the pump. So obviously the heart is the major organ of the Circulatory System.

In the C-Circulation part of the Primary Survey, we are looking for signs of adequate circulation. Is the heart pumping blood well enough to sustain life? Now, AHA had us quit teaching people to check pulses a few years back because, well let’s be honest here, people suck at it. They did a big study and rescuers (professionals and lay-persons alike) were missing pulses on live folks and finding them on dead ones. Instead of trying to locate an artery close enough to the skin for you to feel and counting the beats (which is what we do when we take a pulse), look for things that tell you the Pt is circulating blood. What things you ask? Things like good skin color, movement, coughing, breathing, talking. This isn’t an exact science but if the guy is cold and grey, it’s a pretty safe bet their heart isn’t doing its job. (BTW, the heart’s job is to get oxygenated blood to the brain, everything else is secondary).

If you determine the ol’ ticker isn’t ticking, that’s bad news but it makes things easy for you. Dead people are stable; in fact a person can’t really get any more stable. Now if you don’t lik’m, there’s not much to do here. But, I am assuming because you’re reading this, you probably don’t want to let them die. So…insert CPR class here. As I said before, go take a CPR class. The instructor will spend lots of time showing you, and more importantly let you practice, the skills you need to treat the absence of ‘C’.

Now it gets tricky when they aren’t dead. In all cases, you need to keep them warm; hypothermia is a killer that can sneak in and zap your Pt if you aren’t careful (Goggle ‘Deadly Trauma Triad’). That whole Trendelenburg position (elevated feet) thing has been proven ineffective in most cases so don’t spend much time worrying about it.

We talked a lot about controlling bleeding in the Catastrophic Bleeding part so I’m not going to get into that. If they are still bleeding, get it under control.

TCCC pushes oral fluids in the trauma Pt if they have no altered mental status; they are the only program I know that does. The logic is sound even if the anesthesiologist will be pissed when they arrive at the hospital (water in the belly can become water in the lungs.) Right now, open the TCCC PowerPoint ‘Tactical Field Care’. Okay slow kid, I’ll wait while you go to this website http://www.naemt.org/education/PHTLS/TCCC.aspx and download it….. You really should have done that a few posts ago…. Open the presentation and read slides 122-132 closely. If you happen to have IV fluids AND the training to use them, you can do a bit to help BP but it’s temporary, burns through resources, has a bunch of risks on its own, and if you get carried away (especially in a bleeder) can make the situation worse. If you have fluids in your FAk, read slides 133-139 VERY CLOSELY. Now go unpack the fluids from your go bag. That crystalloid isn’t worth it unless you couple it with high flow exhaust to get them to a hospital, is it? Your call…

One thing that is pointed out in those slides that I think should be emphasized is that the radial (at the wrist, if you can’t figure it out, try youtube. P.S. Don’t check a pulse with your thumb, it contains a pulse) represents a systolic (top number created when the heart contracts) BP of 80mm Hg. That is a great number to bring the half-dead to, especially if they are bleeding. I know you just read it in slide 132 but it’s important so I’ll say it again: “Too much fluid volume may make internal hemorrhage worse by ‘Popping the clot’.” Do not try to get them to a ‘normal’ blood pressure. I know this is a little disjointed, everyone still with me? Onwards then…

We’ve been out at the local range with our trusty sidekick when Tonto takes a round in the upper arm. Wow, THAT is Catastrophic Bleeding! And the way he’s jumping all around and dancing, he’s getting good coverage too! Well, good thing you’re a ZSer and have a Blowout kit right….where the hell is it? Oh crap, back at the truck. Hold on Tonto, I’ll BRB. Well, you get back and Tonto isn’t running and screaming anymore, in fact he’s slowed down a lot. You know, he’s not really moving much...

You spring into action (after throwing on a pair of gloves) and slam the CAT in place and control the Catastrophic Bleeding. Tonto has slowed down but he’s able to answer questions and talk if you really get in his grill. That tells you that, at the moment, he has an Airway and is Breathing. You grab his wrist (not the one on the arm with the extra hole) and feel his pulse (yeah, I told you before we don’t really teach it because people screw it up, especially when they are amped up and think they might be touching a dead guy. Guess you better practice if you want to be able to tell if Tonto has a BP of 80 or greater huh?). It weak but it’s there. This is a good thing. You get Tonto laying flat (not to redistribute blood in his body, because if he falls over and cracks his egg you’ll look like a tool), cover him with his jacket, and get help on the way.

We good? What are your questions? Anyone there?

[foul_ball]

I think the lay people here (myself included) may not have enough familiarity to know what questions to ask, but you've covered CABC, which leaves Diability and Environment/Exposure fair game. Would love to read more from your perspective