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The next ten minutes

A bright flash, a loud bang and you suddenly hit the ground before the smoke clears. Feeling pain, you reach for the source and are surprised to find blood quickly seeping through your once-pristine uniform. Thankfully, backup is right behind you, EMS is only 10 minutes away and the nearest fully equipped trauma room is 30 minutes down the road.

Unfortunately, if bleeding from a serious gunshot wound is not controlled immediately, you could be dead in three minutes. The next 10 minutes are critical, since that’s about how long it takes EMS to reach most of us in populated areas of North America.

Everyone who carries a firearm for a living or spends any amount of time on a shooting range should seriously consider carrying an individual first aid kit (IFAK) in an easily accessible place on their person. You may have to use it on yourself, perhaps with only one hand free, or instruct others how to use it on you. In these and other cases, the well-equipped first aid kit you carry in your vehicle may be just 50 feet too far away.

A good IFAK should have the minimum equipment needed to save your life after a serious gunshot wound for those crucial first ten minutes. It is not a boo-boo or survival kit; it has a singular purpose and is designed specifically to stop uncontrolled bleeding from a gunshot wound almost anywhere on the body. (This is why they are sometimes termed blow-out kits.)

There is no one perfect setup for everyone – as always, let the mission dictate the gear – but recent advancements in combat medicine mean that a few carefully selected items can now be stored in a compact kit the size of a double AR magazine pouch. Designed to help control massive hemorrhaging and simple enough to be applied quickly, these few items can give you the most valuable thing you may need for the rest of your life – survival for those first critical 10 minutes.

Lessons from combat

Two decades of armed conflict in Iraq and Afghanistan have seen significant changes in emergency trauma care for combat casualties. While police officers don’t deal with the same risks, the lessons learned can help keep officers alive on the streets of North America today.

In the 1990s, a United States Special Operations medical research project was undertaken with the goal of improving combat trauma outcomes through optimizing care rendered in tactical environments. The research on pre-hospital trauma care resulted in an article, “Tactical combat casualty care in special operations,” published as a supplement to the August 1996 issue of Military Medicine.

The project’s core principles for tactical combat casualty care (TCCC) are to avoid preventable deaths with effective gear, good training and proper tactics. The guidelines were highly customized for use on the battlefield and concentrated on the three most common causes of preventable death in combat:

• Extremity hemorrhage (60 per cent of deaths)
• Tension pneumothorax (33 per cent of deaths)
• Airway obstruction (6 per cent of deaths)

The US military began equipping every soldier on the ground with a compact first aid kit designed to specifically address these three problems. They were designated as the “improved first aid kit” in the US Army and “individual first aid kit” in the US Air Force and Marines. The items they contained depended on the issuing branch but they were designed for self-aid first and buddy-aid second. In other words, when carried in a place easily accessible to either hand, you would first use the kit on yourself and, if that was not possible, another soldier would use your kit on you.

Combat soldiers have to deal with hospital care that may be hours or days away. Canadian police officers rarely face these circumstances but a tactical situation can be much like a combat zone. The military principle “The best medicine is sometimes superior firepower” is just as applicable to law enforcement as combat.

The items in an officer’s IFAK may be more tailored to conditions at home, but the principles of call for help, win the firefight and patch up the bullet holes haven’t changed in hundreds of years.

What to carry

Emergency first aid is a complex topic. Even with the lessons learned from combat and today’s modern products, the field is constantly evolving. Equipping your own IFAK requires both careful thought and proper training but there are a few rules of thumb that may help simplify your decision process.

Firstly, recognize that if you are suddenly suffering uncontrolled bleeding from a gunshot wound, the best equipped first aid kit in the world – nearby in your car – may not be as good as a minimal kit carried on your person. This means you need to understand what works – and almost as important, what you don’t need.

Secondly, few prepackaged kits contain all top-quality components or will suit every situation, so be prepared to do some research. While it may be tempting to just keep it simple and push the “add to cart” button, remember that human life isn’t simple and you aren’t stupid. There is too much at stake here.

Thirdly, my extensive research, which included talking to everyone from EMS and combat medics to emergency room physicians, taught me one important lesson: the amount of gear people try to stuff into a kit is inversely proportional to their experience in real-life gunshot trauma situations. While that may seem counter-intuitive, it’s a fact; experienced medics know what works and what to leave out. Don’t carry more than you can pack in one small case and nothing that you are not trained to apply.

Since hemorrhage bleeding is the number one cause of preventable combat deaths, there are three main possibilities to address in those first critical ten minutes: a gunshot wound to an extremity or chest or a severed artery. So while tension pneumothorax (a buildup of air from a sucking chest wound) and airway obstructions are the next two causes of preventable death on the battlefield, they won’t kill you in the first ten minutes; uncontrolled bleeding will. Unlike combat troops, police officers can generally leave the latter two for EMS and worry first about stopping the bleeding.

A minimal kit can have as few as five basic items:

• Tan or blue nitrile gloves
• A quality tourniquet that can be applied with one hand
• A self-adhering compression bandage, often known as an Israeli bandage
• Hemostatic gauze to pack into a wound if pressure can’t control the bleeding
• High-adhesive chest seals that can prevent air from entering a sucking chest wound.

Gloves

Nitrile gloves are a necessity. Even dealing with your own injuries, they will help pack gauze deep into a bullet wound. Tan or blue are much better for checking for blood than the traditional black colour.

Tourniquets

Applying direct pressure will always be the first line of defense for a gunshot wound but lessons from Afghanistan and even Boston have shown the value of tourniquets in quickly arresting life-threatening external hemorrhage from limb injury. In these rare situations, they can be life-saving.

Sometimes pressure, packing the wound with gauze and applying a compression bandage just do not work to stem bleeding – or perhaps you are alone or may need to keep two hands free to deal with other wounds. In ongoing tactical situations, it may not be practical to be on your knees for ten minutes trying to stop the bleeding.

To be effective, a tourniquet must be tight. It will cause pain when applied and again when released. Proper training is important. There is a risk of serious complications if it is not properly applied but with modern designs and good training, one should be able to save both life and limb.

In my research, I have found three different levels of pre-hospital tourniquets:

• 1 – High quality combat-tested products such as the genuine Combat Applications Tourniquet (CAT) and the new version of the Special Operations Forces Tactical Tourniquet (SOF-TT Wide.) The CAT is slightly smaller and lighter, thanks to its composite rod versus the aluminum rod of the SOF-TT. Both are extremely well made. The CAT is now standard issue for Canadian troops and has been given to millions of soldiers in the US, Canada and Britain since 1995. Other manufacturers are quickly entering this market with their own unique designs.

• 2 – No-name knock off (what I call “white label”) brands that copy the CAT design and are manufactured by medical supply houses in China. Primarily sold in volume by tender, there is no evidence that they may fail to work as designed. Potential copyright issues aside, I personally wouldn’t buy one just to save a few dollars.

• 3 – Imitation CATs designed for airsoft gamers. These are cheap counterfeit copies made by toy companies in China that go for $14 or so on eBay. They are designed only for the look and should never be used in a real first aid kit. Be aware that the counterfeit tourniquets may be poor quality but are good imitations of the real thing and have fooled more than one combat soldier. Strictly toys and one of the many reasons why I don’t play with toy guns.

Compression bandages

Designed to wrap tightly around a wound and apply needed pressure, compression bandages can often be applied where a tourniquet is not appropriate. Stored in a highly-compressed state, they usually come in four and six inch widths. The best ones are Israeli bandages (most still made, surprisingly enough, in Israel) and the OLAES bandage, named after US Special Forces combat medic Army S/Sgt. Tony Olaes, who was killed Sept. 20, 2004 during Operation Enduring Freedom in Afghanistan.

Applied properly, they are capable of significant compression. One four inch Israeli (commonly called an “Izzy”) fits very nicely into my compact IFAK and I keep several more four and six inch Israelis plus an OLAES bandage in a larger mobile vehicle kit.

If there were one item you would use more often than any other, it would probably be the combat compression bandage.

Hemostatic gauze

Hemostatic products speed clotting of blood and have significantly improved in the past few years. Original products came as a powder or crystal and were sprinkled over the wound and then sealed or packed with gauze. The problem was that the early versions could cause severe burns through a chemical reaction. Emergency room physicians absolutely HATED them because of this and the difficulty in debriding wounds. People also misused them for minor injuries such as fishhooks stuck in thumbs instead of bleeding that couldn’t be stopped through pressure.

The much better hemostatic gauze has now replaced hemostatic agents in most military IFAKs. Quick-Clot Combat Gauze and Celox Rapid z-fold gauze are probably the two best products on the market. The gauze can be packed tightly into a deep wounds to control bleeding or folded into a pad and placed over shallow wounds such as in the head, torso, neck or groin areas where compression bandages don’t work well.

Quick-Clot is impregnated with very fine silica/clay particles to enhance clotting, while Celox Rapid relies on a faster-working material called chitosan, a product of shellfish.

Chest seals

One place you do not need any holes – as if there were any place on your body that you do – is the chest. This includes from the belly-button area to the clavicle, on all four sides. A bullet hole here creates an opening in the chest area and lungs; air sucked through it is just as likely to kill you as the bleeding, which is why they are often referred to as a “sucking” chest wound.

A chest seal is a large adhesive plastic disk designed to stick to the skin and quickly seal up bullet holes. The best ones, such as the Halo Chest Seals, come in pairs, because if there is one hole in your chest, there is likely two. Halo uses a very high adhesive seal that will effectively stick to hair, blood and wet skin.

Before the advent of good chest seals, medics would sometimes use old EKG probe patches or even plastic sheets from bandage wrappers taped on three sides, but there is no reason to waste time doing that today. The only downside to the Halo is its awkwardly sized package, which will likely need to be folded at least twice to fit inside a compact kit.

What you don’t need

Many experts I talked to have seen unnecessary gear take up valuable space in an officer’s IFAK – everything from nasopharyngeal airways, chest decompression needles and even scalpels. Understand that you are not surrounded by combat soldiers who have all been trained in emergency first aid. You may be alone or surrounded by people with minimal or no training. Your kit is designed to be used (first) by yourself and (second) by others on you.

For example, before deciding to put a chest needle into your kit, I always suggest people look around at those around them and decide whether they want any of these folks jabbing long sharp needles into their chest close to the heart. Even experts have difficulty applying chest needles and they are not usually needed in the first 10 minutes, especially if a chest wound is properly occluded with Halo chest seals.

First aid trainers with real life gunshot wound experience usually say that, outside of combat conditions, needle decompression of the chest is not usually very effective, has a high complication rate and is better done as a chest drain at the hospital.

Based on good advice from a combat medic, I even dumped my CPR mask. He recommends to go compression only when doing CPR since using a mask takes regular practice. Most times, people over ventilate and the stomach fills up with air. This causes the body to purge the stomach contents and now you’ve got the big issue of trying to clear out the vomit.

Individual first aid kit

Here’s what I carry in my individual kit:

• One pair tan nitrile gloves

• CAT tourniquet

• Four inch Israeli compression bandage

• Celox Rapid combat gauze

• One pair Halo chest seals

• Sharpie

• Small roll of surgical tape

• EMS shears

The Sharpie is for marking the time of application on the tourniquet; the surgical tape just fills a hole. I also added a few inches of orange paracord to the zipper pulls to help distinguish the first aid kit in a hurry.

Vehicle kit

Due to the amount of time I spend on shooting ranges, I carry a second larger kit in my vehicle for everything that is important but not necessarily critical in those first few minutes. It contains:

• Six pairs nitrile gloves

• A CAT tourniquet

• Four inch OLAES modular bandage

• Four inch Israeli compression bandage

• Six inch Israeli compression bandage

• Quick-Clot Combat Gauze

• 2 packs H&H compressed sterile gauze

• EMS shears

• 12 4×4 gauze pads

• Two Purell cleansing and sanitizing towels

• Two packs Water-Jel burn dressing

• All weather space blanket

• Head-mounted LED light

• Reflective vest

I am not a medic or first aid expert. I researched the top-quality products on the market today but what works for me isn’t going to work for everyone – and new products are being introduced every day. I’ll even admit that over the course of researching this article, my own personal kit has changed. I dumped a few items that might have minimal usage such as sterilizing wipes and a CPR mask. I also replaced a SOF-TT tourniquet in the vehicle kit with a second CAT for simple standardization.

“I continually change my load out depending on what I’ve got going on or what new things I’ve learned,” one highly experienced medic told me. “Like anything it’s an open dialogue.”

Like everything else in police work, survival is good training added to a proper mindset. Good care now is better than perfect care later, after it’s too late. When you’re down on the ground and first see blood gushing from you, there is nothing more satisfying and reinforcing to your survival mentality than to keep yourself busy.

Jam a finger in the wound and apply combat-tested gear to stop the bleeding while you wait for that most comforting sound – sirens in the distance.