So much has changed in the last few years concerning tourniquet use, thankfully. Tourniquets were the

"last resort" for many years and still are in many civilian settings. However, thankfully times have 

changed and as we learn more about the human body, our skills and tools have improved. Tourniquets,

once maligned, are now credited for saving many, many lives after being the first item placed in the

event of a life-threatening hemorrhage. To that end, we need to know the “how?”, the “when?” and the

“why?” when it comes to our first piece of info; “Tourniquet the Limbs”.

An old myth is, "Once you place the tourniquet, everything else below it is dead". False. Tourniquet

placement times up to 2 hours are common not only on the battlefield, but in the operating room. This

prevents blood loss. Blood needs to be in the body and a well-placed tourniquet helps it stay there. It

doesn’t matter whether it’s arterial or venous in nature, bleeding is still bleeding and needs to be

controlled. All bleeding is bad. Full stop. End of story.

There are many instances where the TQ has been in place longer than 2 hours and the victim has still

retained their limb. A nine-month study in Iraq described how there wasn’t a single loss of a limb was

attributed to TQ placement. The limb may have been lost as a result of the injury which necessitated the

application of the TQ, but the loss wasn't a direct result of the TQ placement. Also, the quicker the

bleeding is controlled, the greater the chances of survivability for the victim. Blood belongs in the body.

Period. If hemostasis can be achieved before the victim falls into Stage II Shock (750-1500ml of blood

loss), then the chances of survival are over 90%. If the victim falls into Stage II or greater shock, the

survival rate drops down to less than 20%. Blood carries oxygen, removes waste and has vital clotting

factors. All of those need to be in the body when it is wounded, not leaking out onto the ground. So, get

the bleeding stopped as quickly as possible, however possible. The better our tissues are perfused with

oxygen, the less downstream issues we have to deal with. A victim may survive the initial injury and

blood loss only to die of other related complications later. If they do survive, their organ function may

take a very long time to return to a baseline “normal”, if at all. So, stopping the bleeding and getting the

victim to a definitive care facility to get blood back onboard is going to increase survivability

exponentially.

Tourniquet use is now a widely accepted method of controlling hemorrhage and the majority of the up-

to-date bleeding control curriculum reflects that. They agree with the general consensus that pretty

much all bleeding is bad and that if hemostasis can't be achieved with direct pressure, then move onto a

TQ.

For TQ placement, we teach “deliberate” and “hasty” placement. Basically, a “Deliberate” placement is

if you can see where the blood is coming from, you’ll want to place the TQ 2-3” above that wound,

unless there’s a joint involved, in which case, you’ll want to place it a couple of inches above that joint.

Now, let’s say the scene is chaotic, multiple victims, blood-soaked clothing, poor lighting, etc….and you

just can’t tell where the bleeding is coming from, that’s where you can apply a “Hasty” TQ. You’re going

to place the TQ as high up on the limb as you can and then secure it. This is also called the “High and

Tight” placement method used in CUF (Care Under Fire) scenarios. This type of TQ placement may stay

as it is until the victim is at a higher level of care or it could be “converted” to a “Deliberate” TQ

placement by the First Responders if the wound is easily identified. What they would do then is place a

second TQ 2-3” above the wound, secure it and then release the first “High and Tight” TQ to prevent

more tissue from being affected by no blood flow. This has to be done within the two-hour window we

talk about in class and why it is absolutely vital that we mark any TQ with the time of application. This

two-hour window is very important in that it lets First Responders know how long the TQ has been in

place.

Securing the TQ is another big thing. If you secure it, stop ALL of the bleeding. Veins are lower pressure

and it’s typically easier to stop venous flow, so if you still have an ooze, you may have arteries (higher

pressure and harder to occlude) feeding the extremity and you won't have any return through the veins

as they are occluded. This can cause a dangerous amount of pressure to build up in the extremity and

lead to a life/limb-threatening situation called "Compartment Syndrome". A wound which may have

needed a TQ but wouldn't have resulted in an amputation now does due to a poorly secured TQ. So,

constantly reassess for any bleeding and ensure you can’t feel a pulse below the tourniquet on a pulse

point (ie. Radial artery in the wrist or dorsalis pedis/posterior tibial in lower leg). Once the TQ is secured

and all the bleeding is stopped, you’ll want to note the time and write that on the place provided on the

TQ. If all the bleeding isn’t stopped with one TQ, you can add a second one directly adjacent to the first

one, whether above or below (wherever you have the most room) and then secure and mark the time of

application. Individuals with larger limbs may need more than one TQ to successfully stop the bleeding

because not only does a TQ work on circumferential compressive force, it also acts on the surface area

which is being compressed. Therefore, if one TQ doesn’t work, you are doubling the surface area being

compressed by adding a second TQ and increasing your chances of successful hemostasis.

When do I not use a TQ?? Simple…. if it's not life-threatening. What’s life-threatening? Any of the

following could be viewed as life-threatening:

-Blood pouring out of a pitcher

-Blood-soaked clothing

-Bright red arterial spray

-The victim is lying in a large pool of blood

-The bleeding won’t stop with direct pressure

If the bleeding doesn’t look like the aforementioned, then, more than likely, good old fashioned direct

pressure is going to do the trick. Don’t go “full guns” if your kid gets a minor laceration and you try to

put a tourniquet on their limb. Even small arterial punctures and lacerations can be controlled with

direct manual pressure.

If you have to utilize a hemostatic or pressure dressing to ensure the wound stops bleeding, then go for

it. It matters not whether it’s arterial or venous in nature, it’s still bleeding and blood belongs in the

body. It’s science. Do all you can to keep it there.

Some wounds may need the TQ initially due to an unsafe scene and then can be dressed with a

hemostatic gauze and pressure bandage or may just need the pressure bandage; this is called a

“tourniquet conversion”. Also, some wounds may not be amenable to tourniquet placement and the

only way to control the bleed is through the placement of a roll of hemostatic gauze. Those areas of the

body we can’t apply a tourniquet to are where we are looking at; the “junctions” like where the neck

meets the shoulders, the arms meet the armpits and the legs meet the groin. So, we “Pack the

Junctions”. The key to success when using a hemostatic agent is to get the agent down to the source of

the bleed through constant, consistent pressure and keep applying it until no more can be placed and

then holding pressure for the prescribed amount of time, observing for any re-bleed and then

reinforcing it with a pressure bandage. You’re trying to put as much of the agent in the wound as

possible while the gauze is conforming to the wound and applying compression. If it begins to re-bleed

you’ll have to pull that gauze and place a fresh one in. If you have only one, just pack more standard

gauze (or whatever type of packing material you have on hand) in behind that and continue to hold

pressure and then wrap it and secure it with a pressure bandage.

The hemostatic gauze we utilize in our kits have two different compounds; Chitosan (ChitoGauze) and

Kaolin (QuikClot Combat Gauze and Bleeding Control Dressing). The Combat Gauze helps with the body's

own clotting capability to assist in forming a clot while the ChitoGauze acts completely independent of

the body’s “clotting cascade”. The QuikClot Combat Gauze has absolutely no heat at all associated with

it and won’t burn, while the ChitoGauze breaks down into glucosamine and causes no issues with folks

who are allergic to shellfish, iodine or CT dye as the proteins (what we’re allergic to) are absent. They

are both solid, proven hemostatics. They are impregnated into the gauze to get to the source of the

bleed for better delivery and to start building the clot. The gauze is there as a framework for the clot and

to add compression into the wound.

"But it has to be washed out"....every wound, whether it has the old granules or the newer gauze or

nothing, will be irrigated copiously and debrided in the OR.

“What about sterility?....Sterility is also another big question and that completely goes out the window

when someone is injured. Plus, you'll be getting an equine-sized dose of broad spectrum antibiotics in

the ER anyway. The packaging has to be sterile per FDA requirements but unless the outer wrapper is

sterilized and you open it utilizing sterile technique with sterile gloves in a sterile environment, the

moment you break the seal on the package in the outside environment, while using non-sterile gloves,

sterility is now gone. The least of your concerns at the time someone is bleeding to death is whether or

not something is sterile. It’s a good idea to keep it as clean as possible but we have to know that it’ll

never be sterile after it’s opened. All of the hemostatics we utilize in our kits are solid performers and

have been proven to work in austere environments time and again.

What about packing a penetrating wound to the chest? Nope. We call anything from the collarbone to

the pelvis and allll the way around the trunk, “The Box”. One, we don’t pack anything into a penetrating

injury to the chest, two, we can’t tourniquet it off, three, there’s a lot of ways there that air can get into

the pleural spaces and collapse a lung. So, if we can’t tourniquet it off or pack it, what do we do? We

“Seal the Box” with a non-porous occlusive dressing. The first choice is one which is “vented”. This

means it allows any pressure building up inside the chest to be released passively so that it doesn’t

continue to build and cause an excess of pressure. That said, we must know the signs and symptoms of

a tension pneumothorax because just because you have a vented seal in place over a penetrating chest

injury does not mean that it will be working. There are many things which can occur with this type of

injury which can cause the wound to occlude and not “vent”. So, know your signs and symptoms and

constantly reassess the victim for any increased difficulty breathing and other indicators of this

dangerous build up of pressure. There are many types of chest seals out there and we utilize the HALO

or Hyfin as they are excellent performers and pack easily into our kits and other stand-alone kits.

The key with any of the aforementioned items is learning how and when to use them. Get the training

and be prepared. We offer these products in our kits and the training on how to use them and other

items in the event that you don’t have them with you. The time chooses you. Will you be ready?

For more information on our products and training go to:

www.darkangelmedical.com

SIMPLICITY UNDER STRESS

As you continue working, you take water and bathroom breaks and remind your brother to do the same. He’s always been pretty stubborn and doesn’t get to the cooler quite as often as you.

By around 1300, it’s 100 degrees with a heat index of 110 and zero breeze. It’s miserably hot. You’re getting ready to grab a sandwich and cool off a bit in the shade when you notice your brother’s chainsaw has become silent. You walk around the other side of the truck, talking to him about how hot it is today, and you notice him walking away from you in an unsteady gait. You call out to him, and there’s no response. You run up to him and pull his helmet off. The first thing you notice is that he is sweating like crazy, and his wicking-material shirt is literally soaked with sweat. You put the back of your hand onto his forehead, and he’s burning up, and his face is flushed.

What do you do?

Heat injuries are just as insidious as cold injuries, but they do progress in stages if you know what to look for.

What is it?

This looks like heat stroke. There are different types of heat stroke. Classic and Exertional. Classic is characterized by the person being overwhelmed by the outside temperature, and the body loses its ability to cool, while exertional is caused by the metabolic processes inside the body doing what they normally do, but overheating the body due to dehydration and inability of the core to radiate the heat off of the body, and can occur with relatively low temperatures and humidity.

In either case, heat stroke is a true medical emergency, and we need to get EMS on the way and get the victim cool quickly to prevent organ damage and/or death.

How do you recognize it?

 Their skin can be hot and dry, but depending on the ambient humidity, it may still be moist, and they can still be sweating long into heat stroke. Our bodies cool by evaporation, essentially a “swamp cooler”. But, the higher the ambient humidity, the less evaporation occurs, the more moisture traps the heat, and the less cooling occurs. Thus, it can be said that a higher-humidity environment can cause heat casualties, just as a hot, dry environment, where the victim doesn’t even recognize the rapid evaporation of sweat. Couple this with no breeze and no hydration, and it won’t take long for the situation to become life-threatening.

FYI, heat exhaustion victims may have pale, cool, clammy skin and be very sweaty. They may be nauseated, suffering from muscle cramps, and possibly have vomiting and diarrhea. They are suffering from a form of hypovolemic shock due to sweating out all of their electrolytes and need electrolyte replacement and cooling before they progress to heat stroke.

The heat stroke casualty may have an altered mental status due to the high core temperature (greater than 104 F) and may exhibit nausea, vomiting, and seizures. A major concern, in addition to cooling the victim, is maintaining an open airway and preventing aspiration.

How do you treat it?

Call 911 and get them cool quickly! If you have a thermometer, take a core temperature reading as a baseline (yes, “core” means rectal temperature). In this case, the brothers have some heavy black trash bags in their truck and a cooler full of ice and water. Perfect recipe for recooling.

Get the casualty into the shade, call 911, and attempt to cool them. Get their clothes off and start packing cold packs into the groin area, the base of the neck, and the armpits. Basically, you’re trying to cool the areas where a high degree of blood flow occurs. This helps get the cooling to the core area. Essentially, you’re packing the “Junctions” with cold packs. You can even place a cool cloth in the palms of their hands and place a frozen water bottle on top of it to apply cold therapy to those capillary-rich areas. If you want to be even more aggressive, you could use the bags and lay the victim in them and ‘dam up’ the edges and put ice and water in to form an improvised immersion cooling bath. Constantly monitor (every 5 minutes) for significant cooling. Once the temp is at 102, you can get them out of the bath, as we don’t want to induce hypothermia.

If they are lucid, you may try oral rehydration with small sips of cool fluid. Be very, very cautious and constantly observe for nausea, vomiting, and seizures. Protect their airway!

Wait for 911 to get there, let them know what happened, and let them get the victim to the ER and into treatment.  The sooner the heat injury is treated, the better the prognosis.

Just remember to keep it simple and plan accordingly.

• Around 1L/hr. Alternate water and no-sugar/low-sugar electrolyte solutions.
• Rest periods to cool off. Take 15 minutes out of every hour, at the very least. If it’s too hot, leave the work for another day. Safety first.
• If you’re not urinating every 1-2 hrs, you’re not drinking enough fluid (that doesn’t mean beer, soft drinks, or coffee). If your urine looks like a yellow highlighter, drink more water and electrolyte solutions (low to no sugar is important, as sugar can affect the fluid balance in the gut, leading to diarrhea, which will increase electrolyte depletion)
• Buddy Checks are important. Take care of each other and ensure each other is getting enough rest and fluid.
• Know the signs and symptoms of heat exhaustion and head off any injuries before they progress.
• Know them.

Life is complicated. Taking care of each other is pretty simple.

Until next time, stay safe.

Simplicity Under Stress

If you need a trauma kit, it's by definition an emergency. We'll explain below. 

...

What should be in an emergency trauma kit?

At bare minimum, Dark Angel recommends the following Top 5: 

• Tourniquet(s)
• Hemostatic Gauze
• Pressure Bandage 
• Chest Seals
• Nitrile Gloves

...

You don't need to limit your load to those items (though space/need/organization and sometimes weight are a consideration), but every trauma kit should have at least those items. 

...

What is a trauma kit? 

  In simplest terms, an emergency trauma kit is a "patch kit" for people. Its intent is to stop life-threatening injuries and keep the victim stable long enough to deliver them to more definitive care. 

There are many so-called "trauma kits" out that are really just glorified first aid kits, lacking the things required to address immediate life-threating injuries. For instance, some don't contain anything close to sufficient amounts of hemostatic gauze. That should be a non-starter for anyone making a legitimate trauma kit.  

Our minor trauma kits contain a 4ft. roll of hemostatic gauze (the minimum recommended amount) while our full size (not compact) major trauma kits have a full 12ft. roll of hemostatic gauze. 

Unfortunately, many companies opt for the smaller roll even in their full-size kits for two reasons: 1) to "check the box" that it has hemostatic gauze and 2) to cut cost. 

...

What does IFAK mean?

IFAK is an acronym. It stands for Individual First Aid Kit. 

Get yourself a hexmag or three, put 'em in whatever mag pouches you prefer, and build out whatever sort of war belt you'd like - but you know which of those implements the average citizen is far more likely to end up using? That trauma kit. 

...

Is there a difference between a trauma kit and an IFAK?

There can be a difference between a trauma kit and an IFAK depending on its content, but the term is basically synonymous with any kit that can assist in immediate response to life threatening injuries. 

One of our kits, the HARD Case, contains a range of materials from minor first aid kit items like small bandages and gauze pads up to major trauma items like tourniquets and hemostatic gauze.

...

What should be in your IFAK?

That Top 5 mentioned above definitely belong in there. Other items like mylar blankets, eye shields, and nasal airways, may have a place depending on what you are doing, and where. It's not a bad idea to add some sturdy tape and a marker, just remember to know where your items are!

The stress of a chaotic situation in the presence of one or more life-threatening injuries will cause confusion. Confusion wastes seconds and seconds can cost lives.

 ...

What are the advantages of a CAT tourniquet compared to other TQs?

While there are several solid CoTCCC-recommended/approved TQs out on the market, the CAT, especially in it's current 7th generation, is currently recognized as the gold standard for controlling extremity hemorrhages. 

...

It stands out from others in that it was purpose-designed to be applied quickly and easily with one hand and with diminished fine-motor control as well as under conditions of reduced strength. All of these occur when someone is bleeding heavily and under the influence of the body alarm response. 

...

Y'all stay safe.

Kerry

These following comes from a study done by the US Army Institute of Surgical Research (USAISR*): 

Bleeding Out

1. An adult weighing 150-180 pounds contains about 4500-5700 ml of blood. Once a person loses 750 ml (around 15% of blood loss), they go into the first stage of hemorrhagic shock in less than a minute. 

Not to fret: stopping the bleed after this much blood loss results in a 94% survival rate. 

However...

2. Once a person loses 750-1500 ml of blood (around 15-30% of total blood volume) the survival rate moves to only a 14% survival rate.

We want you to be able to stop a bleed before you lose more than that 15% to increase your chances of survival. This is why we designed our kits to be fast and effective. 

Having the proper med kit, whether it's on your person or strategically staged in a vehicle, workplace, or home, allows you to be able to respond to a severe bleed immediately. Equally important is to GET THE TRAINING! 

Having a med kit is a huge step in the right direction, but you need to be able to respond effectively and to do that, you need to practice. Remember, time is of the essence and you are your own first responder. 

You could be dead before an ambulances reaches you.

Updated DARK IFAK

In keeping with the need to keep our kits fast and effective, we recently updated and upgraded some of our DARK med kits. 

We've added a rip-away panel option and custom TQ pouches (for CATs and SOFTT-Ws) to the options you can choose when you make your purchase. 

These are our new tourniquet (TQ) holders. They're designed to hold either the CAT Gen 7 or the SOF-T Gen 5. It utilizes just channel of MOLLE/PALS webbing to attach to our DARK pouches or DARK Slims. Or for that matter anything that carries PALS-compatible channels. Each is marked with a TQ so it's readily identifiable in an emergency, under stress. 

See, here's the thing. All the battle belt gear and available reloads in the AO won't help you stop the bleed. You can have a 5.56 magazine on every finger, a 12,000 lumen EDC light in your hand, and the knife Rip Riley gave you for birthday in your pocket, but none of that will do much to deter a little thing we like to call exsanguination. 

And that's why you need a medical kit of some sort. And some basic medical training. 

Above: here is a good look at how the DARK attaches to a belt. You can attach it to any MOLLE panel or PALS compatible webbing we've seen to date.If you're not running, wearing, or using gear with this sort of attachment, no worries. There are many different kinds of trauma kit available. 

We are always looking to make our products as top notch as possible. We are constantly innovating to put out the best and most effective trauma kits on the market. If you have questions about the kind of kit that might work best for you and your mission/lifestyle/job/needs, hit us up. This is what we do. 

Get a kit. Get trained. Be the difference.

US Army Institute of Surgical Research

USAISR's mission is to provide combat casualty care medical solutions and products for wounded warriors, from self-aid through definitive care across the full spectrum of military operations; provide state-of-the-art trauma, burn, and critical care to Department of Defense beneficiaries and civilians; and provide Burn Flight Teams. You can find many of their studies and formal study results online at (https://) usaisr.amedd.army.mil/publications2015 (.html). They research a wide variety of medical-related matters, from Battlefield Pain Management to Extremity Trauma and Regenerative Medicine. For example, check out what they're doing with Tactical Combat Casualty Care: (https://) usaisr.amedd.army.mil/01_tc3 (.html)

Don't Bleed Out

A Leading Cause of Death

The risk of life-threatening hemorrhage from traumatic injury is estimated to be the leading cause of death of Americans between 1 and 46 years of age.

Bleeding out from traumatic injury is the mostly cause of death if you were born after about 1974.

Kinda makes sense to takes some steps, doesn't it?

Read this:

...Outside military conflict, severe bleeding accounts for greater than 35% of pre-hospital deaths and nearly 40% of deaths within the first 24 hours of injury.

Recent intentional attacks (Hartford, Las Vegas, Parkland, and others) have highlighted the threat posed by severe bleeding. Such attacks have occurred in high traffic locations such as schools, theaters, malls, universities, churches, and concert venues. Military bases have suffered these attacks as well...with 35 killed, and 57 wounded since 2000.

The importance of early hemorrhage control, along with rapid identification of immediately correctible causes of death, has proven to save lives, and has evolved into a cornerstone of Tactical Combat Casualty Care (TCCC). This knowledge has already been adapted by the civilian groups such as the Committee for Tactical Emergency Casualty Care (C-TECC), and is becoming standard practice for civilian law enforcement, as well as tactical and emergency medical services teams worldwide. 

Recent mass casualty events and battlefield experience led to the Hartford Consensus in 2013, which calls for all responders – including bystanders – to have the education and necessary equipment to stop severe bleeding immediately in the field.

Widespread use of AEDs has saved lives and has demonstrated effective use by the layperson. A simple and inexpensive hemorrhage control kit such as Bleeding Control basic (B-con) kits offer similar advantages to AEDs from an ease of use standpoint, and may even prove easier to use given the simplicity of tourniquet application. Additionally, the lives saved from traumatic hemorrhage, in general, are young, healthy individuals with many years to live compared with the typical patient requiring AED use.

First Aid is what is done immediately after recognition of a sudden illness or injury and can, indeed, be

lifesaving depending on what type of incident has occurred, the actions need to be taken and what

items are on hand. What we want to do is try to separate and clearly delineate what they are in our line

of work. Is minor, non-life threatening first aid warranted OR do we require more aggressive first aid

(trauma care) due to life-threatening trauma? As we say in our classes, the situation dictates the

medicine.

Minor first aid are our “boo-boos”, while major first aid (trauma kit) is some type of injury which

requires immediate actions to be taken in order to preserve life. A minor first aid kit has more “comfort

care” items for situations that aren’t life-threatening. It is equipped for minor lacerations, abrasions,

minor burns, aches, pains, stings and other minor things. It typically isn’t equipped with any components

necessary to deal with massive trauma. So, we’re looking at adhesive bandages, small pieces of gauze,

over-the-counter pain meds, antiseptic wipes, sting wipes, burn gel and other items for life’s everyday

cuts and scrapes.

A very comprehensive first aid kit can have some life-saving components in it and that’s okay, but know

where they are, because in the first instance of trauma, it’ll become a “tactical yard sale” as all of the

“stuff” is being strewn in every direction while that “one” item is being sought out. The more “stuff” you

put into a first aid kit, the larger it becomes. The larger the kit becomes, the less likely you are to carry it.

That’s why we try to maintain a balance of compact sizing along with maximum efficacy. The smaller,

more compact and easier it is to carry, the more likely you are to carry it where it belongs; on your

person.

A trauma kit has the basic necessities to help with the things that will kill us the quickest, the first being

massive life-threatening hemorrhage. At a bare minimum, you need to have a pair of gloves (non-latex

due to latex allergies) to protect you from body fluid-borne pathogens and a scientifically PROVEN

tourniquet, not the latest “cool guy” tourniquet or a frickin’ knock off from China. Next, you should have

some sort of hemostatic gauze like QuikClot Bleeding Control Dressing or a chitosan-based product like

ChitoGauze along with a pressure dressing to reinforce the hemostatic agent and hold it in place. Then,

add a pair of compact chest seals in there so that you have the ability to “stop the bleeding and start the

breathing”. Those are literally the basic foundations of a “trauma” kit.

What your first aid or trauma kit doesn’t need in them unless you are trained AND certified to use them:

Suture kits, chest decompression needles, surgical airway kits, chest tube kits, endotracheal tubes or any

other advanced, invasive procedure devices. Why? They are a HUGE liability and they take up valuable

space that could be occupied with more pertinent devices like tourniquets and hemostatic gauze. I’ve

yet to hear of a major trauma victim needing to be sewn up in the field at the site of the injury.

Any of the other stuff mentioned above, unless you’re an MD, NP or PA, stay away from it. It doesn’t

matter if you watched it on YouTube or took a TCCC class, unless you have those licenses you CANNOT

legally perform those procedures. Even if you’re a CCEMTP or Flight Paramedic, you can’t perform them

unless you’re under direct medical control.

Basically, know what’s in your kit, where it is and, most importantly, how to use it. Clear delineation of

your items (minor vs major) will greatly increase your chances of finding what you need should the

situation arise. Just because an advertised kit has “more stuff” in it most certainly doesn’t make it

better. In actuality, it can make things worse because chaos causes confusion and confusion causes

hesitation. Hesitation is something that is not conducive to life in a traumatic incident.

Furthermore, only place items in them with which you have been trained on or you are otherwise

certified/licensed to use. Stick to the basics of trauma management; “Stop the bleeding, start the

breathing, treat for shock.” and everything else will fall into place.

Get a kit. Get trained. Be the difference.

Y'all stay safe!

The phrase  Knowledge is power (scientia potentia est) is usually attributed to Sir Francis Bacon and his Meditationes Sacrae. It dates to back to the 16th century - 1597 to be precise - but is absolutely as true today (in its common interpretation, anyway) as is was more than four centuries ago. 

Knowledge in this instance can be representative of literal knowledge, evidence-based and experience-based tactics, or anything similar. It can be gained in books, training and education (including the "School of Hard Knocks"), and by hands-on familiarization. 

Whether you are an individual or part of a family, you must continually strive to maintain a reasonably constant, reasonably maintained state of readiness (which includes what some folks refer to as " tactical fitness", but really is just a pragmatic and life-contextual level of physical conditioning).

One of the best ways to do that is through training on a daily basis. We practice fire drills and tornado drills. Why not practice other drills, as well? Do you rehearse plans for  home invasion? Problems encountered in your daily life, or that you might encounter in overseas adventure travel?

“That’s impossible," some may scoff. "Who has time?" Or, "That's an overreaction. Too paranoid, too expensive, too..."

Actually, it can be both easier and faster than you think, and it certainly won't break the bank. 

Visualization.

Give yourself several scenarios every day while you’re out and about. In your car, in the store, at work and especially at home. Figure out what you will do for each scenario you give yourself and what the potential outcomes will be. Think of it as “dry-firing” for your brain. Go through each step thoroughly, visualizing your every move, to include what you would do after the scenario like scanning, reassessment, activating 911, etc. It’s like exercise for your brain and it helps you more than you realize.

Kinesthetic feedback.

Some of us with firearms practice “dry firing” so that our drawstroke is faster and more efficient and our sight picture and trigger press is consistent all in the effort to get better and improve our skill set. This all benefits us in that singular moment in which we may need to call upon those skills and we’ll be able to act without thinking about the mechanics of the draw, the sight alignment or the trigger press.

Essentially, it increases our chances of surviving a life-threatening encounter. Now...

...how many of you who own practice tourniquets do dry fire practice with a practice tourniquet?

...are you more likely to have to utilize medical skills or firearms skills in everyday life?

We need to see the importance in training for this possibility and make time to practice these scenarios in real-time, and run through them utilizing your equipment “for real”. Actually putting your hands on the equipment, both hands, is huge. Work with your dominant and non-dominant hands to gain speed and dexterity. Some current and prior military personnel might call such things "TDGs", or "  Tactical Decision Games".

Example:

What would you do if you were sitting in your car at a red light and a carjacker’s attempt on the car beside you went bad and a round fired from their gun went through your car door and struck you in the leg, severing your femoral artery.

How long do you have to react? What is your first priority? Have you trained with a TQ while being seated and belted into your car? In the dark? Upside down because you've rolled over?

How about employing your concealed carry weapon from that position?

Getting the “bugs” out before you have to use the training is a huge factor in having a successful outcome. Practice it over and over so that when and if the time comes you’ll react and take care of the problem without really thinking about it. as you will be subconsciously skilled from multiple correct repetitions. You’ll see the problem, recognize what it is and fix it. Simple as that.

Mindset.

When we wake up, every day, we’ve got to put into our minds, the thought, “Not me. Not my family. Not today. Not any day.” Steel yourself mentally. Don’t give up. Having the proper mindset is key to surviving many bad situations. Whether it be a life-or-death encounter with an armed madman or a life-or-death encounter when your arm goes through a plate glass door and severs an artery, proper mindset is a key to survival.

Knowledge.

No matter how stubborn we may be, we have to have the knowledge to back it all up, to ensure an optimal outcome in a life-threatening situation. Knowledge is power and it can give us the power of life. Know what to do and more importantly, why to do it. We must understand that each situation is fluid and we need to know how to adjust to it. Be comfortable pushing yourself outside the envelope of conventional thought and be outside “the box”.

Be a continual student.

Challenge yourself to learn something every, single day.

It’ll make you a positive contributor and an asset to society rather than a liability.

Dark Angel Medical can provide you with the training, the training equipment with which to hone your skills learned in class and the “real world” products. Whether the unexpected needs is personal (i.e. an event that overtakes you and your family) or professional (such as the immediate aftermath of an  officer involved shooting), all you have to do is bring the right mindset and that is a personal choice.

Get a TOURNIQUET and carry it. 

You can choose to prepare yourself accordingly and live or you can choose to do nothing and accept the less pleasant outcome. It may take some work but the end results are beneficial to you and those around you. If not for yourself, do it for those you love.

Get the SELF AID BUDDY CARE knowledge to use it.

They may not be afforded a choice, and your knowledge and mindset may be the difference between life and death.

Y'all stay safe out there,

Pocket Doc

Suddenly, a car, ‘cheating the curve’, comes around the bend at a high rate of speed and sideswipes the van. Out of control, the van lurches off the side of the road and rolls end-over-end several times in a deafening crash of breaking glass and twisting metal as the car flies into a stand of trees. You immediately get close to the edge of the road, turn your emergency flashers on, call 9-1-1 and give them your location and let them know what happened and that you’re going to try to help. You grab your first-aid bag with your D.A.R.K. and head down the steep embankment.

The first thing you notice is that the van is right-side up but severely damaged. You hear high-pitched cries and voices calling for “mama”. As a parent, this is a nightmarish scene, but you press forward.

The car ‘cheating the curve’ has hit the trees on the edge of the road and you get to it first and notice an adult-sized figure resting on the hood of the car face down. As you get closer, you notice a large pool of blood on the hood and that half of the driver’s face is gone. The eyes are locked open and there are no signs of life. There are no other people present in this vehicle, so you move on to the sounds of voices.

You first see two small children, a boy and girl, around 8-10 years old, crying and sitting just outside the van. You ask them what happened and they tell you that they got out of their seat belts and got out of the van, so you direct them to go sit down at the base of a couple of trees away from the van and the other vehicle. As you’re continuing to move to the van, you hear an adult female voice scream, “Help my babies!!!” and you hear a small child crying, coughing and calling out, “Mama!!!” As you reach the van, you see the child strapped into the booster seat in the left rear passenger seat behind the female driver. The child appears to be about 4 years old and has frothy, pink bubbles coming from an area on her left upper chest and it looks as if it came from a jagged piece of metal. You look up front and see a bright-red spray of blood cover the windshield and see that the female’s left arm is severely injured. It’s hanging at a severe angle below the forearm and spraying blood in a pulsatile manner from a large wound in her forearm.

You deploy your TQ, wrap it above the elbow and tighten it down until no bleeding is present. As you’re doing this you tell her that it won’t feel good but it will help. She tells you, “It’s ok, just help my babies.” You then grab your HALO seals and expose the little girl’s injury and wipe away any blood, affix a seal to the front and check the back for any exit wound. Finding none, you grab your shears and cut her seat belt and keep her in her booster seat and take her over to where her siblings are seated, all the while, talking to her and reassuring her all will be ok. You then come back and help the mom out of the driver’s seat and have her sit next to her children. You grab some mylar blankets out of your bag and wrap everyone up in them, talking with them, gauging their mental status and keeping them calm.

You check on the boy and girl, grab your gauze and shears and begin to dress their small, superficial cuts and, just as you’re done, you thankfully hear the wail of approaching sirens.

You’ve just completed triage and treatment of multiple motor-vehicle accident victims to the best of your ability.

Remember, triage means “to sort” and by doing that, we are simply doing the most good for those whom we can actually help. This means in a mass casualty situation such as this, we have to adhere to some basic triage principals and categorize them with colors according to their injuries.

Our Minimally Injured/walking wounded are our “Green” patients and can either treat themselves or be left to attend to until later due to the lack of severity of their injuries.

The most Immediate patients, “Red”, are those who are in danger of bleeding out or have airway or breathing injuries and can be corrected rapidly with an immediate life-saving intervention. Basically, if they have any of the following, they’re an Immediate:

1. Life-threatening hemorrhage
2. Airway injuries
3. Trouble breathing
4. Weak or absent radial pulses
5. Inability to follow commands/Disoriented

You’ll notice we had two of these. The mom was in greatest danger due to life-threatening hemorrhage while the little girl’s open pneumothorax, while still critical, could wait a little longer than the mom. You may have to triage within categories just like this.

Once stabilized, an immediate could be downgraded just as a lower category can be upgraded if they degrade. Just remember to constantly reassess the victims frequently, gauging mental status changes or other signs and symptoms, checking TQ’s and bandages, respiratory effort, etc.

Our Delayed patients are those with sprains, fractures that can wait to be stabilized after more urgent patients (the “Red” category patients) are attended to and are “Yellow”.

The final category is Expectant or “Black” in which we can’t do anything at the POI (Point of Injury) to assist them. These are patients who have no obvious signs of life or who have sustained such grievous injuries (exposed brain tissue, near decapitation) that our limited capabilities would be ineffectual and would be time spent on them that we could be spending assisting others who both need and would benefit from our aid. Move on to those you can help.

Triage is not about selecting who lives and who dies but is about helping those whom you know you can help in the quickest, most effective manner possible. Our skills in triage may be called upon in something as ‘simple’ as a motor vehicle accident. If there’s more than one patient, triage principles apply. If you happen to come to one of our classes, we guarantee you that you will come away with the confidence of knowing that you could make a difference in a situation like this, because If you wait until the accident happens before you seek training, then you’re already too late.

Get a kit. Get the training. Be the difference.

You dry-fire with a SIRT gun once a week, or practice your drawstroke a couple of times with your weapon before rolling out for the day - gotta make sure you can get the retention system unlocked to clear leather or move your cover garment before getting your gun out, right? Parents, ever run fire drills or get-to-the-shelter drills for a tornado?

Now, how many times have you "dry-fired" with your tourniquet? Have you ever practiced getting into your EDC kit (or to your kit, wherever it is)?. 

Would you be able to get that tourniquet on, successfully, in under 20 seconds?  

Would you be able to put it on with one hand? 

Would you be able to put it on at night? 

If you can't answer these questions in the affirmative, then you need a little practice. Just that little bit of practice, those few reps,, can make a huge difference in your uninterrupted ability to walk around and breathe on this earthly plane. 

Proficiency in both hard skills and soft skills is important, but be pragmatic. Research different kinds of scope reticle; trick your truck out as a survival vehicle. But put some effort into selecting the best tourniquet and combat gauze too, and then make sure you know how to use it.

So, here's the point. Before you get out there this weekend, take just a few minutes out to get some good reps with your training tourniquet (NOT your SHTF use real world tourniquet). Put it on your leg a couple times using both hands. Put it on one arm using the other. If you really like to party, lay down with your back on the floor and your feet up on a chair and practice putting it on one of your legs. In the dark - like you've been in a vehicle rollover, or a cock-up in the world's worst Ferris Wheel. 

Just a few minutes before you go out this weekend. Because when an accident occurs, you have the rest of your life to figure out how to fix the problem. 

The time chooses you!

Too easy. That's 'cuz it'll stop bleeding better than dirty socks from your gym bag. 

Combat Gauze

Seriously, because it's going to to stop bleeding far more effectively than a nearby rag from the shop (or the second spare mag you carry instead of an  EDC first aid kit).
 

Combat gauze is one of the most widely known, widely used, and easily accessible hemostatic agents in existence. It is responsible for a lot of saved lives. Basically, we use a hemostatic gauze to pack into those areas that aren’t conducive to tourniquet use. Those are usually the “junctions” of our body. (See tourniquet use/combat gauze application diagram below).
 

The junctions are areas where something meets the central point of the body, i.e. neck meeting shoulders, armpits meeting thorax, thighs meeting groin, etc.
 

These junctions hold many large vessels that, should they be opened, will contribute to a life-threatening bleed. 

You carry a combat gauze in a trauma kit to the range - excellent. Do you make a routine of having basic trauma necessities with in everyday life?

Carry something in your day pack, in the pocket opposite your wallet, or around your ankle. Hell, throw it into the back park of your tobacco pouch if you want, just be sure to carry something! 

Hemostatic Gauze

  Hemostatic gauze works in a couple of ways.

• It helps form a clot a lot faster than it would form naturally and...
• The gauze helps hold pressure inside the wound and also gives the blood something to “stick” to.

This helps to form a clot and, thus, stop the bleed. Amazingly, this is usually accomplished in less than a couple of minutes: so you can see how much better it is than jamming a t-shirt, shop towel or dirty gym sock down into the bleed.
 

Using something "field expedient" like that would mean you'd have to put about 30+ minutes of heavy, direct pressure on the wound. That's fine if nothing else is available (the  best IFAK to use is whatever you have available and the basic first aid training + mindset to use it), but it's better to prepare for such a contingency in advance with the most optimal materials - like the QuikClot dressing found in the Pocket DARK EDC trauma kit. The stark contrast between bleed-stop times should be more than sufficient cause for the inclusion of combat gauze when planning to build an EDC kit.
 

Once the bleeding has stopped we'll be concerned with keeping that clot stable. Extra movement can cause a clot to break open, which results in a re-bleed. That's why we wrap that sucker up tight, reinforce it with a pressure bandage, and keep an eye on it! 

If your trauma kit doesn't have combat gauze or a similar hemostatic dressing in it, then your trauma kit is incomplete! If you're buying a trauma kit from somewhere else, make sure it comes with a hemostatic dressing in it. There are trauma kits out there that don't carry one so that they can keep their prices down. Don't want to buy one of ours? Fine - but you should still spend that additional $40 and get a kit with a hemostatic agent aboard.

No, this isn’t a story of the paranormal where the characters are tormented by an uneasy spirit and go to all lengths in order to rid themselves of it. The only ghosts in this story are the remains of past incidents which have caused regrets. These ghosts can only be exorcised through the ritual of training.

Many of us know through our own painful personal experiences that you cannot change the past. Conversely, we also know that the only way to prevent ourselves from repeating those past mistakes is to make a positive change and become the difference between life and death. In this case, training makes the difference. Medical training, more specifically.

In the last decade, I’ve taught thousands of people and in every class, I ask them what has motivated them to take this training. There are so many reasons why they are there. Many of them are into preparedness and it’s another box to tick. Many of them are parents and want to be ready to help their children should something bad happen. The list literally goes on and on. Most of the reasons are proactive reasons where nothing bad has happened yet, they just want to be ready just in case it does. However, I think the saddest stories I hear are from the ones who are taking the class based on their own personal tragedies. Tragedies in which they couldn’t help. Scenarios in which they were powerless and could only stand idly by, praying for someone, anyone, to show up that could help. The hurt you can see in their eyes as they relay these, sometimes heartbreaking, stories is horrible. It’s palpable. You can literally feel their pain and regret. You can sense that they are haunted by their choices, actions (or lack thereof) and past reasons. Their reason for taking the class is the hardest and most painful one, being reactive.

Being reactive rather than proactive is the way that many people choose to live and it seems like it’s the majority sometimes. Their reasoning for being reactive is that nothing bad has happened to them yet so there’s no need to worry. Or, they have someone with them who knows “all about that medical stuff”. Or, my personal favorite, “I got all the training I need from when I joined the military twenty years ago”. The excuses can go on and on. And, yes, they are excuses because there is literally no valid reason why someone shouldn’t have current, accredited medical training in these trying times. Things have changed drastically over the last decade, not to mention over the last twenty to thirty years, so we need to make sure that the instructors aren’t just instructors, but teachers who have pride in their craft and who have dedicated their lives to learning how to better help suffering humanity, not someone who just regurgitates information without the slightest idea on what the rationale is behind it nor how to properly explain it.

“It’s probably good enough” or “I don’t need that” are phrases which have no place in many aspects of life, especially medical training. To be satisfied with mediocrity is to give a silent testimony that one doesn’t believe that their life is worthy of the best. This is especially true when so many offerings are out there that are “great”, “outstanding”, “current”, “relevant”, etc. To be satisfied with outdated information is akin to having the best, fastest internet speeds offered and the offer is rejected because dial-up is “probably good enough”.

Let’s say that someone witnesses a motor vehicle accident with multiple casualties. Most of these casualties have minor lacerations and are otherwise unharmed. However, there is one with an open femur fracture which has severed the common femoral artery and they are rapidly bleeding. “It’s probably good enough” and “I don’t need that” witness the accident. How good is the outcome going to be for this patient when one person still thinks that tourniquets are a last resort and the other person has never had any training whatsoever? It’s a rhetorical question.

While one attempts, in vain, to find a pressure point, because direct pressure over an open fracture isn’t tolerated by the patient and they can’t elevate the extremity, the patient continues to exsanguinate and ultimately expires from massive blood loss which could’ve been treated. The other person simply stands there. Numb. Paralyzed with fear. Uncertain. Haunted.

This incident will live in their collective subconscious forever as will the choices they made (or didn’t make) which could’ve led to a positive outcome in this situation for all concerned, most importantly, the patient. Truly they will be haunted by what happened.

How can one get better? Get the training. Obtain the proper equipment. Prepare yourself mentally and physically. That’s it. I know, it sounds so simple. That’s because it is simple. There’s no wildly complex algorithm. This ain’t rocket surgery!!! Our medical training program is proven, simple, comprehensive, easily digestible and, wait for it….fun! Yes, this training is a lot of fun. The student will leave with a sense of empowerment and quiet confidence. They will feel that they truly can, and will, make a difference. Will they do it perfectly when called upon? Maybe. Maybe not. But, and this is a HUGE “but”…they are doing SOMETHING. They are acting quickly and decisively, thereby doing their absolute best in order to affect a positive change in this patient’s outcome. THAT, my friends, is how you become “the difference”.

We may not be able to change the past but we can most definitely do something positive in which we can change our course in the future. This will most certainly help get rid of the “ghosts of bad decisions” and give us a more rewarding outcome rather than live with a multitude of “what if’s?”.

Like we always say, no one is coming for you. You are it.

Our training last sixteen hours but regret lasts forever.