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Survival Medicine and Ditch Medicine, by Josh in Montana

There may come a time when we are no longer afforded the luxury of dialing 911 to receive prompt emergency medical care within minutes. You yourself may be faced with a sick or injured loved one, having nobody to turn to but you and your skills as well as inventory of supplies to provide critical interventions.

My lively hood is emergency pre-hospital medicine. Having earned a degree in Paramedicine in 2002, I have worked and currently still work as a full time paramedic for a department that sees over 4500 runs a year. I myself serve as lead medic or, “team leader” on close to 200 runs or “calls” per year. Over the past six years, I have participated in over 2500 emergencies first hand. I feel obligated to offer this article to those of you who may not have such an exhaustive exposure to injury and illness in the out of hospital setting. I also serve as a local tactical paramedic on the police department SWAT team, where I am affectionately referred to as “Doc”.

I would recommend to any of you interested, in researching your local educational programs or community colleges in search for a Emergency Medical Technician Basic course. This is a short duration and fairly entry level class on basic life support.

Most of us here are familiar with a G.O.O.D. pack. Equally as bulky and most likely as heavy would be a medical bag. Now, any tactical team with a medic is than going to have one guy, the medic, carrying a large medical bag. The one I carry for SWAT is easily over 35 pounds, perhaps 40. In addition, every member of the tactical team should also be personally equipped with a, “blow out kit”. This is a small personal medical bag that is clipped to either a hip or belt rig and part of your web gear. I will provide inventories for all of these items later on.

More important than all the trinkets, goodies, cool stuff and gnarly items you can purchase and put into a pack, is the knowledge of how to use and apply those items to an injured or sick patient. You must educate yourself on the pathophysiological process of the many illnesses and injuries you may encounter. This can be done over time, with the right books and reference materials. I recommend Mosby’s Paramedic Textbook in conjunction with the Merck Manual, Emergency War Surgery, and Where There Is No Doctor. Another book that I value as a paramedic is The Street Medic's Handbook.
Knowing the priorities of the sick or injured patient is broken down into a simple and common pneumonic called. “the ABC’s”. It is the fundamental order in which the caregiver approaches the sick and injured patient. I will try to walk you through the mindset of find and fix patient care that hopefully you can put into your tool box and never have to use.

When first alerted to the fact that you have an ill or wounded individual, you must first take into consideration your own personal safety. You must ask yourself, “Is what happened to them, going to happen to me?” This is critical not only for your safety, but to prevent you from also becoming wounded and no longer being of use to your team or others. After determining or making the scene safe, by either neutralizing the threat or dominating the location with support from other members you can begin to approach your patient. Keep in mind this would be different in an indoor verses outdoor scenario and also different for medical versus trauma.

When approaching the patient, you need to begin to observe them. Look for their movements, obvious injuries that you can see as you approach. Listen for gurgling or difficulty breathing. Talk to them and see if they respond. With this information, as you approach, you can form a general impression of the patient. Are they conscious? Can they move on their own power? What is the nature of the illness or the injury? Can you see any bleeding? Are their eyes open and staring, fixed, gazing, or looking around and able to focus? Are they conscious or not?
Once you are at their side, you begin a rapid assessment of the ABC’s. You find and fix problems as you go. Keep in mind on an emergency scene with a critical patient, we often use up to 3-5 paramedics for a serious patient. Two is the minimum number of caregivers you would want for a patient.

First you assess their level of consciousness. Ask them four simple questions. Who are you? What happened? Where are you? What time/day/month is it? This is referred to as alert to person, place, time and event. Most of us can answer these four questions 100% of the time. Unless severely intoxicated or suffering from a head injury, stroke, or shock, people can answer these questions. This gives you an idea as to the patients mental status and level of consciousness.

Next comes the all important (A) Airway. The airway is key. The airway refers to the nose and passages behind it (nasopharynx), the mouth and the area posterior or behind the tongue (oropharynx). Without an adequate airway, your patient will die and die quickly. The airway must be checked and rechecked on all critical patients. Common problems you will encounter with the airway on the sick or injured will be: fluids such as blood or emesis (vomit), foreign body obstructions (choking), broken teeth, tongue blocking airway, and head positioning. The airway of the patient, if the patient is unable to clear themselves, must be cleared by a caregiver. Depending on the mental status and present condition of your patient, will depend on how involved you will need to be in maintaining the airway. Also I must state that any severely injured patient due to trauma (car accidents, falls, assaults, etc.) must be thought of as having a cervical spine (neck) injury. This makes all care more complicated, as this patient requires cervical spine immobilization as well as full body immobilization to a long back board until cervical and spinal injury have been ruled out. This is a complicated and controversial issue, and different agencies have different protocols on how and when paramedics can rule out a spinal injury with assessments done in the field. Any numbness, tingling, paralysis, “electrical shock” feelings, in the hands or feet or legs must be thought of as indicative of a spinal injury. In that case, God be with you.

When approaching the airway, look inside and only remove items you can see. The fluids can be remedied with a portable hand suction. A patient that continues to actively vomit should be placed on their left side and allowed to expectorate (cough up) the vomit. Assist with suction to remove fluid. The risk of aspiration is increased in the unconscious patient. Aspiration is the act of taking in foreign material into the pulmonary (lungs) space. This can lead to aspirated pneumonia and death. I will not explain the many Basic and advanced procedures for maintaining an airway, as these can be found in further reading. Remember, if you don’t have an airway, soon you won’t have a patient!

(B) Breathing is the next assessment stage. In tactical medicine bleeding comes before breathing. Just remember here, that you should look for and immediately fix any profuse bleeding, especially arterial bleeding. I will address this in the circulation portion next. For breathing, you need to look, listen and feel to see if the patient is breathing adequately to support life. An adult should be breathing 12-20 times per minute. Interventions are required for respirations less than 8 per minute and more than 30. Look for chest rise to see and count if the patient is breathing. Listen for the movement of air at their mouth, as well as listen for adventitious sounds that indicate problems with the airway or lungs. Look to make sure the chest is rising equally on both sides. A stethoscope and the knowledge of what to listen for is critical to understanding the respiratory status of a patient. Wheezes, rales, rhonchi, stridor, silence, all of these represent a variety of different events that may be taking place in a patients pulmonary system. Problems with the breathing must be properly diagnosed or ruled out and fixed as you find them.

(C) Circulation, is as you guessed, the “C” in the ABC’s . Find and fix bleeding. When I say bleeding, I mean the kind of bleeding that is going to kill them today, not the little raspberry on their knee. Here you will ascertain the hemodynamic status of the patient. Feel for a pulse at anterior lateral forearm where the wrist and thumb come together. Right over the joint of your wrist you should feel a pulse, if not you are in the wrong spot. Look it up, this is the radial pulse. With this present you can be pretty certain that the patient has a blood pressure of anywhere from 80-90 systolic. Also count the rate. Count the beats in 15 seconds and multiply by four. That is how many beats they are doing in a minute. The average adult is at 80-100 beats per minute. Without exercise, anything past 100 indicates a fast hear, or tachycardia and can indicate blood loss, shock, illness, sepsis, or a variety of other problems. Other locations to assess a pulse are the neck or carotid, the femoral (over the crease where your upper thigh meets you pelvis).

Controlling bleeding is done by a variety of measures. If one does not suffice, continue to do it while moving on to establish the next treatment. First is direct pressure over the wound with bandage or gloved hand. Next, elevate the wound above the heart. Then there is the pressure point. The pressure point is the major artery that feeds the area you area attempting to control bleeding from. You go above the wound, or between the heart and the wound site and provide direct pressure to the artery. Last and highly controversial, requiring training and experience is the tourniquet. Many new products have arrived due to recent global conflicts. QuickClot is a new product designed to hasten the clotting factors and form a clot over a wound. This can be ordered from numerous Internet vendors.

While assessing circulation after you assess the pulse rate, quality and rhythm, you should look at their skin color. Are they pale? Is there skin dry or sweaty? Are they cool or hot? If you are privileged to have a cardiac monitor, put them on it and see what their heart is doing. You most likely don’t have one, and if you do you most likely know how to look at rhythms, so I don’t need to go into that and you don’t need this article. Circulation is this, pink warm and dry is good skin. Pale, cool and diaphoretic (sweaty) is bad.

Assessment of the skin and circulation will aid you in determining if your patient is suffering from shock. Shock is the lay person word for hypoperfusion or the lack of oxygen carried to cells. Cells start to die and this causes more cells to die. The five types of shock are hypovolemic shock (low blood volume) either due to blood loss or dehydration, Cardiogenic shock (bad heart), neurogenic shock (spinal injury), anaphylactic shock (severe allergic reaction), and septic shock (severe infection). All of these require rapid and correct interventions within short time frames for patients to survive.
After your initial assessment, you can move on to assess the patients disability and neurological functions. Check their grip strength, sensations in feet and hands being equal, motor skills, etc. For the elderly or any potential stroke patient I perform a Cincinnati stroke scale here or earlier if that is my suspicion. Get a set of vital signs now. Heart rate, Blood pressure and respirations. Splint and stabilize any fractures returning them to the anatomical correct position. Assess the pulses of any fracture before and after adjustment. Administer oxygen if you have not done so already.

Finally if time allows, get a SAMPLE history from the patient. This acronym stands for Signs and Symptoms, allergies, medications, pertinent past medical history, last oral intake and events leading up to event.

Supplies For Medical Kit:
Oxygen Bottle*, Non-rebreather mask, Nasal Cannula, IV supplies*,
Magill Forceps, Leatherman tool, Stethoscope, Blood Pressure Cuff,
Gloves, Face shield, Flashlight, Advanced airways*,
Hand Suction NPA’s OPA’s, CPR Pocket mask, Bag valve mask,
Syringes, #10 Scalpel, Variety of Gauze pads,Stretch bandages,
Trauma pads, QuickClot, Waterproof tape, SAM splints x2,
Trauma Shears, Hemostats, pen-light, Glucometer,
Glucose gel, Occlusive dressings, Transpore tape 3”, Cloth tape,
Advanced Life Support Medications*

*Indicates prescription only and illegal to possess items unless under a doctors care, supervision or operating in the emergency pre-hospital environment.

A "Blow out" kits contain far less items and only essentials for minor wound care.

I hope this helps someday in a time of need, and serves as an introduction into pre-hospital care. Provisos: Do not take this as gospel. Do nothing illegal. Do not perform any of this care based on this article alone. Always use discretion and call 911 immediately in an emergency (while it is still up and running). Educate yourself further and be diligent. Medicine is important and the knowledge you gain may save your life or the life of a loved one. Take care.

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