Once more with feeling, “Carry your damned blowout kit!”

Lots of good stuff here. My advice is to not carry one blowout kit, but to carry two. Remember that your blowout kit is only for you. If you share it, what will someone use on you, when you get shot?

So yes, carry two blowout kits. One for you, and one to share. Its evidence is manifest once again. These things save lives. Yours doesn’t have to look exactly like mine; but at least read my rationales. Even if you don’t know how to use it, carry it anyway. Someone else there might just have the skills, but not the resources.

See my kit recommendations here: http://wp.me/prx0A-2i (contains both recommendations and peer-reviewed rationales)

Washington Post Staff Writers

Friday, January 21, 2011; 9:57 PM

TUCSON – Some of the first deputies to arrive at the scene of the Jan. 8 shooting rampage here described a scene of “silent chaos” on Friday, and they added that the carnage probably would have been much worse without the help of a $99 first-aid kit that recently became standard-issue.

Pima County Sheriff’s Department deputies said they were dispatched to what they believed was a routine shooting. But they arrived, they found a blood-drenched parking lot that looked more like the scene of a plane crash. Sgt. Gilberto Caudillo got on his radio and pleaded, “Send every ambulance you have out here.”

“Innocent people looked like they were just massacred,” Caudillo said Friday.

He was among about 10 sheriff’s deputies who found themselves doing the duties of paramedics rather than police. In the six minutes before paramedics flooded the site, they had to stanch chest wounds, open injured airways, apply tourniquets and try to calm down victims and the blood-covered bystanders who tried to help.

“We told them, ‘All the bad stuff is over, you’re safe. We’ll stay by your side,’ ” said Deputy Matthew Salmon.

In the end, 13 of those shot survived, while six did not. One of the injured, Rep. Gabrielle Giffords (D-Ariz.) was the last person still hospitalized until Friday morning, when she was discharged and transported to a rehabilitation facility in Texas.

Doctors and law enforcement officials told reporters here that the incident would have been much worse without a small brown kit devised by David Kleinman, a SWAT team medic who had become concerned about rising violence.

Kleinman cobbled together the Individual First Aid Kits out of simple items used by combat medics in Iraq and Afghanistan: an emergency bandage pioneered by the Israeli army; a strip of gauze that contains a substance which coagulates blood on contact; a tactical tourniquet; shears that are sturdy and sharp enough to slice off victims’ clothing; and sealing material that works especially well on chest wounds.

The items in the kit were each inexpensive; the Israeli bandage, for example, cost only $6, but deputies reached for one “over and over at the scene,” Kleinman said.

It is unusual for police officers to carry such medical equipment, but Capt. Byron Gwaltney, who coordinated the sheriff’s office’s response to the shooting, said it proved crucial in this case because the deputies were the first to arrive.

“It would have been a lot worse” without those tools, Gwaltney said. The deputies were trained to use the kit, in a program the Pima force called “First Five Minutes,” six months ago.

The deputies who initially responded said they were not the ones who arrested the suspect, Jared Lee Loughner. Instead, their focus was conducting triage through the parking lot: figuring out who was dead, who was injured and who was simply a helpful person who had jumped in to help.

They used the tourniquets and gauze to stop the bleeding. They used a chest seal, also in the kit, to close bullet wounds. They used the shears in the kit to cut off the victims’ clothes.

“When I look back, I don’t know if we drowned out the moans to focus or if it was quiet,” said Deputy Ryan Inglett, who treated several victims with combat gauze and assisted in CPR. “This is something I will never forget.”

sandhya@washpost.com horwitzs@washpost.com

Edit: Here is a picture of the kit that the PCSD is using:

It’s a simple kit. I like a little bit more; but it will work.

This is WHY you carry your blowout kit, in addition to your pistol:

http://www.fox13now.com/videobeta/e9d0a8fb-6e2d-4182-9ae8-a24387c48c42/News/Two-injured-in-stabbing-on-Jordan-Parkway-Trail

 

TAYLORSVILLE, Utah – An 18-year-old woman and her friend were stabbed in Taylorsville Wednesday night while walking on the Jordan River Parkway Trail. Both she and her friend were allegedly attacked by three male Hispanic suspects, according to Unified Police Department. The 18-year-old was said to be seriously injured after being stabbed in the torso, while the other, a male, was said to had been stabbed in the eye. Police say that the couple encountered the three suspects on the trail, but did not give details regarding whether they knew the suspects or were possibly ambushed. FOX 13 will have more on the incident as details are released.

Copyright © 2010, KSTU-TV

Listen again: “We understand there were several witnesses that came to the aid of the young man and young woman who were stabbed…” A pressure dressing and a hemostatic bandage might have saved her life.

Carry your pistol, reload, and blade; but also carry some kind of blowout kit.

I asked an old-timer once, “How often do folks die around here?”

More later. I am having troubles wrestling with the HTML
His reply: “Only once.”
Continue reading

Blowout kit light stick

The only real feedback I have heard so far about the new blowout kit essay is regarding sizing the NPA and OPA. I will get some pictures up showing how to size them appropriately tonight, if I don’t have to fight with the light too much.

Here is an addendum showing how (and why) I stuck that light stick in that Ziploc bag. I hope you enjoy it.

In the blowout kit essay, the photos demonstrate some of the contents of the kit in a Ziploc freezer bag. This is so that one can grab the bag and have enough of the contents all at once to treat a wound without having to fumble for the smaller items. The text notes, and one picture shows, a blue cyalume light stick adhered to the bottom of the bag. This work will explain how to do it, and attempt to explain the rationale.

Firearms trainers will tell one that a majority of shootings happen at night. Tracking down credible statistics is difficult. On the other hand, half of all time is night. Regardless of the probability, the possibility is there that one will become hurt, possibly grievously so, at night. Car accidents and assaults often occur at night. We should be able then to treat a wound in the dark. It might not be smart to attempt this with a handheld tactical light. First, they are far too bright to use without ruining the night vision of all involved parties. Second, they make using two hands to treat yourself (or to treat your buddy with his blowout kit) difficult. A headlamp is a viable option, but I am including a light stick for two reasons. First, you can use the light to find your other light (headlamp or small LED with blue filters). One can use it to see immediately all of the contents of the bag. Grab it. Break it. Shake it. The contents of the bag are visible. Again, blue is the preferred color because it does not wash out blood the way a red stick, for example, would. Creating a shade for the stick puts the light where it is most effective, on the contents of the bag. It is conceivable that one could be treating that same buddy in a hostile environment. As such, the light needs to go in one direction. Light discipline is something one should always consider before the fact.

Start with an unwrapped blue cyalume light stick. The directions on the package instruct the user not to open the pouch until just before use. Research reveals two points to their rationale. First, the pouch has a positive pressure. The gas inside the package protects the ampule inside the stick from breaking accidentally (this ampule contains the active ingredient that starts the chemical reaction that generates the light). Second, the ingredients do not react favorably to sunlight. Exposure to the sun diminishes the effectiveness of the light stick. Replacing the stick at least annually should mitigate this.

Tear off a narrow strip of aluminum foil (figure one). This will be the reflector. Aerosol 3M Super 77 is the adhesive used throughout this project (figure two). One can use it to create temporary or permanent bonds. Since this project has one of each, it was a perfect choice. Spray the shiny side of the aluminum foil and wait a few minutes for it to become tacky. Then place the light stick on the foil along its midline, with the loop facing down (figure three). Carefully smooth the piece of aluminum foil over one-half of the light stick (figure four).  Use a razor or utility knife to cut away the excess foil (figure five). Next, perform a similar procedure with a piece of gaffer’s or duct tape (gaffer’s being preferred). Carefully cover the aluminum foil and cut away the difference. Your light stick is finished (figure six). Finally spray some adhesive on the stick. Since you are only putting it on one surface, you will be able to remove it easily later. Push the light stick against the bottom of the bag, in line with the seam (figure seven).

light stick

(Figure one, the new stick and aluminum foil)

Super 77

(Figure two, 3M Super 77 adhesive)

foil stick

(Figure three, the light stick on the foil)

end view

(Figure four, carefully cover half of the light stick)

trimmed

(Figure five, trim away the excess foil)

taped

(Figure six, tape over the foil)

inside

(Figure seven, adhere the light stick to the bottom of the bag)

This process takes more time to describe than to perform. When finished, you will have an effective battery-free light in your blowout kit, where it will do the most good. The more preparations made before an emergency, the greater the odds of survival. When building a kit whose contents are strictly to treat serious bodily injury, a few moments of preparation are preferable to the alternative.

Blowout kit redux

(Edit: this is a more extensive version of the “first five minute kit” carried by the Pima County Sheriff’s Department)

I don’t know how many of you read my original blowout kit article. It was on my old Myspace page. Here is round two. Comments are not only encouraged, but requested. This is a first draft; I expect to edit it in time.

About three years ago the owners of the now closed FBMG in Draper, Utah presented a comprehensive, multi-day emergency preparedness course. The instructor there meant for the class to be a “teach the teachers” class, and that the students would become a cadre to teach their friends and neighbors.  The serious nature of the class and course material and later seeking out and acquiring to recommended items and skills, started a chain of events that continue through today. One of the class modules included a brief presentation on the blowout kit- a small kit for the treatment of serious injuries that one could always keep in an LBV, range bag, glove compartment, or large pocket. The concept was new, and recognition of the benefits of having one of these kits, and the skill to apply effectively the contents of the same, was immediate. Unfortunately, many otherwise astute members of the gun culture and preparedness community have a fascination with firearms, sometimes to the detriment of other areas of preparations, including medical preparations. These individuals may take little thought of the consequences of such an infatuation with firearms, in the possibility of a gunshot wound, whether accidental or intentional.

In those days, the movement to ensure every shooter keeps his or her blowout kit for personal use was still in its infancy. There is a growing trend towards having blowout kits, but they are not as prevalent as they should be. There are several reasons why gun owners may not build or purchase such a kit. The gun owner (particularly a CCW holder) may not understand the vital importance of such a kit. They may not know where to acquire these kits, whether prepackaged or home-built. Others may hesitate to get one (or several) because they feel their skills are not up to the prudent application of the contents. It is important to carry one, even if the owner cannot use it. It is a possibility that in the event of a shooting or other traumatic event, that a friend or bystander will have the skills to use these items to save a life. They may balk at the cost of training, considering a simple gunshot wound treatment class may cost several hundred dollars. Some see the expense of such kits and decide against it, judging maybe that more firearms or other preparedness items are a better investment. This is folly. How much is one life, especially your own life, worth? If one considers that cost against that of a complete blowout kit and it becomes trivial.

Since building that first kit, the author’s skills have improved, and understanding of the rationales behind the kit’s individual items has grown. Part of carrying such a kit, like much of the rest of preparedness, is that it is not a checklist approach, but a commitment to improve. In two years, your kit may look somewhat different than it does now, even as this kit has some different items than it did three years ago. “Mindset, skill set, tool set” is the mantra of preparedness. Education and training will affect what you place in your kit. Again, the author is not a doctor or primary health care provider, and this information cannot take the place of formal training. The author presents this essay as information only. One should always seek the advice of local skilled professionals, and call 911 in the event of an emergency.

The blowout kit is to prevent death. Serious bodily injury is a foregone conclusion, since it was precisely what caused the opening of the kit and the application of its contents. It is to save its owner’s life while further help is en route, whether by ambulance or helicopter (or someone drives the owner to the hospital, in a worst-case scenario). It is not for the owner to use on someone else (unless you pack more than one). The three consequences of injury of the greatest concern here are hemorrhage leading to hypovolemia and exsanguination, airway obstruction, and tension pneumotorax. Consequently, the blowout kit addresses these three causes of death common to victims of violent crime or severe accidents in general, and gunshot wounds in particular.

The primary concerns of the pre-hospital caregiver are airway, breathing, and circulation, the ABCs. However, extremity hemorrhage is the most likely cause of death from trauma (possibly because of the prevalence of lifesaving body armor- get some), due to rapid blood loss, and as such, the majority of the kit focuses on it. Nevertheless, in a primary assessment, remember the other considerations. Exsanguination can be very quick in the worst case. This kit contains two Israeli battle dressings, two packages of packed Cinch Tight gauze, one 4×4 HemCon dressing, one three-inch ACE bandage, and one ratchet strap tourniquet, all to deal with severe bleeding. The HemCon dressings are amazing, if you can find them. They are less than half the thickness of the newest QuikClot Combat sponge dressings, which in turn are thinner than the older ACS+ sponges. All of these hemostatic agents are fairly idiot proof. Find the bleed. Put the dressing on the bleed (or in the wound). You do not want to use these on minor injuries. They are much too expensive, and it would be a waste of resources. Use these on life-threatening bleeds only. One can use the gauze to hold the hemostatic in place or to pack a wound.

The tourniquet is an often-controversial piece of kit. Anecdotes abound regarding their use. Unfortunately, these anecdotes are not evidence-based, and tend to portray use negatively without fact. The best evidence from uses in Iraq and Afghanistan demonstrate the tourniquet’s effectiveness at saving lives when applied judiciously. In an emergency, a tourniquet is effective at occluding arterial bleeds. Current methodology is to apply the tourniquet before treating the wound in the case of severe bleeding or amputations. If the wound will respond to direct pressure, a tourniquet is contraindicated. To use the tourniquet, place it between the wound and the heart, as close to the wound as possible and tighten to stop bleeding.

It is often beneficial to place the tourniquet above the knee or elbow, even if the wounds are distal to the joint. The brachial artery supplies the arm with blood, and is close to the humerus before crossing the humeroulnar joint. At the elbow, it splits into five arteries, three of them lying between the radius and ulna. Similarly, the femoral and deep femoral arteries are close to the femur. Inferior to the patellofemoral joint the femoral artery crosses the splits into three arteries that run between, posterior to, and anterior to the tibia and fibula. It is less difficult to stop the bleeding then at the primary arteries, even if the bleed is distal to the joint, since there is likely only one vessel to occlude, and it is against one, rather than two bones.

With the tourniquet in place, treat the wound with the hemostatic agent and pressure dressing on wound. After twelve to eighteen minutes, loosen the tourniquet and assess for continued bleeding. If bleeding continues, retighten and assess again. If the bleeding has stopped, loosen the tourniquet. One may retighten it later if necessary. In the event of an amputation, remember to apply a gauze dressing to the bone fragment in addition to the flesh of the limb, to stop bleeding there. Transport the patient to a hospital immediately.

The tourniquet demonstrated started as a ratchet strap tie-down. These are inexpensive and achieve total occlusion in moments. One makes the tourniquet by running a loop of material large enough to fit over the owner’s booted foot through the ratchet, and ties an overhand knot in the end to prevent it from slipping through. Add a second overhand knot to about six inches of slack to provide a grip. Place it in the kit so that the owner can use it with one hand on any of the four extremities. One can use the ACE bandage to hold a dressing in place, increase the pressure applied to a wound, or to protect a partially amputated limb or digit.


(Figure one, the kit on an ACT AT83 LBV)


(Figure two, the kit)


(Figure three, the kit opened)


(Figure four, the bag removed, note second ARS needle and light stick)

Maintaining an airway is vital to the patient’s life. If the patient is unconscious or has a bilateral lower jaw fracture, the tongue may close the oropharyngeal airway (Venes, 2005). For CPR, one should use the jaw thrust technique to ensure airway patency. Artificial airways provide an open airway for patients who have, or are at risk for, airway obstruction (Wilkinson & Van Leuven, 2007).When the patient has facial trauma, but is conscious, one may use a nasopharyngeal airway (NPA). The NPA is a flanged, flexible latex tube that inserts through the nostril to the pharynx. Conscious and semiconscious patients tolerate these better because they do not stimulate the gag reflex. To insert, lubricate generously with a water-based lubricant, carefully insert into the parent’s naris and twist while inserting. Remember that the nasal cavity is straight for some distance, before turning inferiorly at the nasopharynx. The distal tip should come to rest there, inside the patient’s nasopharynx (Venes, 2005). The larger the size NPA, the longer the tube is. One can generally size them by holding the flanged end at the patient’s nostril, and tracing it to the end of his jawline (Wilkinson & Van Leuven, 2007). This is the best practice for sizing an NPA. Many still size them by comparing the inside diameter of the NPA to the patient’s smallest finger. This practice is not evidence-based, despite still being included in some texts. NPAs use French sizing, with larger numbers indicating a larger tube diameter.


(Figure five, the nasopharynx)


(Figure six, sizing an NPA)

The oropharyngeal airway (OPA) is a curved rigid plastic device that creates a patent airway by holding the tongue away from the posterior of the oropharynx. It has a flange at the proximal end that keeps it from slipping too far into the patient’s mouth. Sizing the OPA is similar to the NPA. Holding the device outside the patient’s mouth and against the cheek, it should be equal in length from the corner to the mouth to the earlobe (see figure six). Turning it upside down will help with sizing. It should be neither too short nor too long, as either will not ensure a patent airway. To place the OPA in an unconscious patient, hold the proximal end with the curve ninety degrees from the curve of the tongue, insert, and rotate it down, allowing the OPA to hold down the tongue. Do not use this device on a conscious patient, as the intact gag reflex will preclude proper placement (Venes, 2005). If the patient is even semiconscious placement of the OPA will trigger gagging, vomiting, and laryngospasm if airway reflexes are intact (Wilkinson & Van Leuven, 2007). Experts contraindicate artificial airways if basilar skull fractures are likely. Additionally, stabilize and secure the head of unconscious patients to prevent cervical spinal cord injury and paralysis (Venes, 2005).


(Figure seven, sizing the OPA)


(Figure eight, an OPA and NPA)

Tension pneumothorax is a life-threatening event caused by both penetrating and nonpenetrating chest injuries. Fractured or dislocated ribs are the most common cause of tension pneumothorax from nonpenetrating injuries. In either instance, air entering through the chest wall or the pleural cavity causes intrapleural pressure to exceed atmospheric pressure. Air will enter, but not leave the pleural space, resulting in the partial or complete collapse of the affected lung. Air build-up will push the mediastinum, or organs and tissues separating the lungs (Venes, 2005) to the opposite side of the chest, causing the trachea to push against the blood vessels of the neck and the lung to put pressure on the vena cava, impeding venous return. Both of these cause a life-threatening impairment of blood flow to the brain. Early signs (besides visible trauma) include shortness of breath, pain, increased heart rate, and asymmetrical chest movement. In its late stage, trachea shift is also visible.

Treatment in emergencies is by needle aspiration of the affected lung. In the event of a sucking chest wound, first cover the area directly over the wound with an airtight dressing, preventing air from reentering the pleural space. Then aspirate the affected lung with a large-bore needle between the second and third rib at the second intercostal space (between the ribs), in line with the patient’s nipple (the mid-clavicular line), just above that third rib, and over the top of it. To palpate the location of the needle, remember “soft, hard, soft, hard, soft”. Start at the patients shoulder. The first “soft” you feel is the trapezius muscle. The first “hard” is the clavicle. The second “soft” is the first intercostal space. The second “hard” is the second rib. The third “soft” is the needle’s target, the second intercostal space (see figures eight and nine).  Remove the needle when the sound of the escaping air stops. This kit contains one Hyfin chest seal and two North American Rescue ARS for Needle Decompression. The Hyfin seal is effective at adhering to wounds even when the skin is wet or hair-covered. The ARS needle is preferred over standard angiocatheter needles in instances where law enforcement may become suspicious of hypodermic needles.


(Figure nine, the second intercostal space)

(Figure ten, needle placement for aspiration of a tension pneumothorax)


(Figure eleven, Hyfin chest seal and ARS for Needle Decompression)

The last items in the kit are for convenience and comfort. The kit contains one pair of EMT shears (to remove clothing).  It also contains one Mylar “space” blanket to treat shock, two individual packets of water-based lubricant (for NPA insertion), one pair of size large nitrile gloves (for the person working on the kit’s owner), one burn dressing (just in case), and one blue cyalume light stick (because blue contrasts well with blood and does not damage night vision). The light stick is shaded with aluminum foil and gaffer’s tape and glued to the inside of the kit. Since a majority of violent encounters happen at night, it is wise to prepare for such. One other important factor to consider is pain. If you have some leftover scheduled analgesics (hydrocodone, oxycodone, etc.), you might want to put them in there. Keep them in the original container, if possible, to dissuade law enforcement intervention.


(Figure twelve, gloves, lubricant, burn dressing, Mylar blanket)


(Figure thirteen, blue light stick inside bag)


(Figure fourteen, small contents in bag)

Another consideration is space. It is easy to make a kit so large that one cannot easily carry it. If it is not convenient to carry, many opt to leave it at home or vehicle and it will not be there when the trauma happens. The contents of the Zip-Loc bag could easily be a small kit unto itself, and fit into a thigh BDU pocket. Some have advised the possibility of vacuum sealing the contents. If you do this, ensure you can open your kit with one hand, and without any tools. You may be cold, with slippery, bloody hands, or may be with only one hand when you need it.

Remember again that your blowout kit is only for you. It is for you or others to use on you in case of one of the injuries described above. Everyone in your party should have his or her own kit. If you wear it on your person, you should be able to access its contents with either hand. The author does not recommend thigh-mounted kits for this reason. The nasal and oropharyngeal airways should be of appropriate size for the kit owner. Kits that are more generic (as for a third party) would likely dispense with the NPAs and OPAs in favor of only dealing with hemorrhage and tension pneumothorax and not a collapsed airway.

This essay cannot take the place of formal training. It is only a reference for building your own blowout kits, with rationales for selecting kit components. Many competent firearms schools and instructors now offer classes on the treatment of gunshot wounds. If one is not interested in the complete education to become a medical professional, this is an excellent option. Preparedness is about acquiring and practicing the skills necessary to save lives in a catastrophic event, or its aftermath. Recent events in Haiti show the consequences of a lack of preparedness. Like the police, when seconds count, EMS is only minutes away. Plan for the possibility of treating yourself or someone you know for hemorrhagic blood loss, collapsed airway, and tension pneumothorax due to gunshot wounds, car accidents, or other events likely in your region. Remember, when it is least expected, you are elected.

(I have recently substituted the ratchet strap tourniquet for the CAT. Although my friends with the 19th SFG still carry the ratchet straps, I wholeheartedly endorse the CAT as effective, highly occlusive, and lighter/less bulky. Expect a review soon.)

Works Cited

Porth, C.M. (2007). Essentials of pathophysiology: concepts of altered health states, second edition. Milwaukee, WI: Lippincott Williams & Wilkins.

Wilkinson, J.M., & Van Leuven, K. (2007). Fundamentals of nursing: theory concepts & applications. Philadelphia: F.A. Davis Company.

Venes, D. (2005). Taber’s cyclopedic medical dictionary. Philadelphia, PA: F.A. Davis Company.