Gunshot Wounds to Extremities: “Be Trained, Be Prepared, Be Competent.”

Who I Am

Let me take a brief moment to introduce myself. My name is Dwayne McBryde. I have been involved in the tactical and EMS community for well over 25 years.  I have “real world” experience drawn from the United States Marine Corps, U.S. Navy, Fire Service, Executive Protection, and as a Private Government/Military Contractor. I have several combat/high threat deployments under my belt as a medic in the Middle East and Afghanistan. I have been a Texas Paramedic for 20 years, 10 of which I wore a dual hat as a Navy Corpsman with the Marine Infantry and Scout Sniper community.

I currently deploy to Afghanistan where I serve the U.S. government as a medic in a capacity I am not at liberty to discuss due to security clearance reasons.  I am by no means a “know it all,” but I do consider myself a qualified subject matter expert in the areas of Tactical Medicine gained by real world experience in arduous conditions under very difficult circumstances.

U.S. Law Shield approached me and asked me to do some monthly articles on tactical medicine and I agreed. This is my way to give a little to the shooting community and all the CHL carriers who protect themselves and their families every day in America. I’m sure you have figured out by now that I am by no means a professional writer by far. Most of these articles will be written during down time while deployed to Afghanistan. I will attempt to keep the subjects interesting based on real-world incidents and outcomes.

The Scenario

You decide to have some bonding time with your kids on a beautiful Saturday morning at the local gun range. You get to the range; it’s a perfect day for shooting. You do the responsible thing and go over the range/firearm safety rules with your kids. Just to ensure (like your father did) that firearm safety is passed down and practiced. You figure out quickly that you were not the only genius with the idea to go shooting today. The pistol lanes are jammed up, and there are just three stalls open in the line-up to accommodate you and your two young sons. You put on your eye pro, ear pro, and check to make sure the kids follow suit. You follow range rules and move up to the firing line with your unloaded firearms and equipment. Down to your left a shooter has knocked his loaded magazines off of the shooting bench and has bent over to pick them up with his firearm in his right hand. You’re helping your sons get their gear squared away. All of a sudden, your world is turned upside down. You hear the discharge of the firearm and notice the oldest of your two boys crumple to the ground like someone flipped a switch. You notice, above the screams of pain, bright red blood squirting from his left thigh.

YOU HAVE 90-120 SECONDS TO SAVE HIS LIFE… WHAT DO YOU DO?

When Seconds Count

The first thing that happens in these type situations is your body and mind revert to your highest level of training. Just like all things under high levels of stress, reaction time and fine motor skills reduce considerably. As mentioned, you can only perform to your training level. Ask yourself if that level is consistent with the responsibility and love you carry for your family and friends. You now have the ability to gain the knowledge needed to assist your loved ones in that time of need. This article is designed to give you the needed knowledge and insight to gain the necessary skills to do so.

The range scenario above is  based on a real incident that I witnessed several years back (characters and story line changed). I was attending some training when a range safety rule was violated resulting in a gun-shot wound (GSW) to another person on the firing line. The trainee was picking up empty mags after a string of fire. His pistol was not holstered, a negligent discharge occurred, and therefore he shot his partner to the right of him.

This scenario also reminds me of an incident a few years back of a similar situation that occurred back home.  A gentleman shot himself while violating the same exact safety rule. He was without the aid of trained personnel. He bled out and died on the shooting line before EMS could respond.

I can attest that most EMS response times are going to be over eight minutes depending on the location and its distance from the closest EMS/Fire Station. Other factors that play into response times are:

  1. Is the responding unit already on a call when another call comes in?
  2. Is the ambulance that is posting for the truck on a call already in place when your call drops?
  3. What are the traffic conditions at the time of the call, etc.?

Factors such as these can affect response times in both the rural and suburban setting. Incidents happen in every area of shooting and training. It does not matter if you’re a civilian or a team guy, incidents happen. I will add that nearly all of these incidents happen due to safety violations, complacency, horseplay, poor training, poor firearm handling skills, or just plain old ignorance.

The Science Behind Saving a Life

All medical advice in this article will be based on Tactical Combat Casualty Care guidelines and principles. Why TCCC you may ask?  Because TCCC requires no formal training and is very effective medicine for shooting or tactical-based incidents.

Now let’s get back to the meat and potatoes of the article. What we have here is a non-self-induced GSW to the left thigh resulting in a complete dissection of the left femoral artery in our patient. I will attempt to break this down in simple terms for general understanding on the technical end and then we will follow up with treatment modalities.

The body is the most complex machine on the planet with the ability to compensate many times over before crashing. We are focusing on a major bleed, in this case, secondary to a GSW. The body’s cardiovascular system (CVS) consist of the heart (the pump), the container (arteries and vessels), and the fluid (whole blood). I also like to add the lungs. It is an important component that supports the cardiovascular system. It filters off waste and supplies oxygenated blood to support healthy perfusion of the body’s cells.

TCCC – There are three levels of care under TCCC.  They are as follows:

  1. Care Under Fire;
  2. Tactical Field Care;
  3. CASEVAC Care or Casualty Evacuation Care.

In the Care Under Fire phase, we focus strictly on stopping all major bleeds. In this phase, you are under accurate hostile fire and mitigating the threat and gaining control of the gunfight is a priority. In the tactical world, the best medicine in a gunfight is rounds downrange. You can’t do anything for anyone if wounded, and the upper hand not achieved. This may not be the normal situation at home.  Ask yourself, is it any different with an armed assailant in your home?  Is a close-quarters battle (CQB) any different in Baghdad than it is in your living room? NO!  Bullets cause the same trauma in Texas as they do in Kabul. You can quickly find yourself in a Care Under Fire situation in your home. The threat must be mitigated  before other causalities happen. Knowing what to do and gaining the knowledge and skills to stop life-threatening bleeds will help save loved ones.

The body can go without oxygen for 4 minutes before any major damage occurs, but you can bleed out from major blood loss in 2 minutes or less (depending on body size). The average human body contains 5-6 liters (5000-6000 cc/ml) of blood. Loss of 25% to 40% of that total blood volume will create a life-threatening condition known as irreversible shock.

There are many forms of shock. We will focus on hemorrhagic shock due to the nature of our wound. Shock is a condition that affects the CVS and if not addressed in a timely fashion will ultimately result in death. Shock can be defined as poor perfusion, meaning there is not adequate blood flow to supply the body’s cells with oxygen and nutrients. Waste starts to build up, and cells begin to die ultimately resulting in death. Perfusion takes place in the smallest of the body’s arteries/vessels called the capillaries. It is here that oxygen and nutrients are exchanged for waste to support a healthy metabolism and a state of homeostasis within the body. An interesting fact here is that the CVS circulates its entire volume of blood through a healthy body in 1 minute. In our scenario, the effects on our patient are disruption of the fluid and a container of the CVS. Without proper intervention, the patient will die due to pump failure secondary to hemorrhagic shock. The only way to prevent this catastrophic event is to stop the arterial bleed in the patient’s left thigh as quickly as possible.

Stopping the Bleed

The most effective way to stop a major arterial bleed to an extremity is the proper administration of a tourniquet (TQ). Our dad in the scenario is prepared and keeps a blowout kit on his belt when at the range shooting. He grabs his Combat Application Tourniquet (CAT TQ) and applies it to his son’s left leg about 5 inches above and proximal to the wound. He tightens down the TQ until the bleeding stops completely. He activates EMS simultaneously, and the child gets transported to the nearest medical facility and is stabilized. With less than $20 in gear and proper knowledge of TQ application, the father saves his son’s life.

On the civilian side of EMS, we were taught for years that a TQ was always a last resort. On the tactical medic side, we are taught that the rapid application of a CAT TQ is the quickest way to ensure the prevention of serious blood loss during an engagement with hostile forces when treatment abilities are limited.

Studies from Iraq and Afghanistan have proven this fact by the enormous amount of lives that have been saved. The old school of thought was that a TQ promoted limb loss if left on for an extended period therefore putting it last on the list for necessary interventions in the field. The War on Terror has proven otherwise with successful results from TQs that have been left on for hours before reaching definitive care.

Speaking from first-hand experience, I advise going to the TQ to stop major blood loss to extremities.  CAT TQs are cheap and can be purchased online from North American Rescue. They are simple to operate and can be administered with one hand very easily. CAT TQs are the preferred TQs of the United States Military and most Federal Agencies. There are many documented cases of shooters applying their own CAT TQ and getting back on their weapon system to stay engaged to get control of the fight. Keep one in your gear and position one on your body somewhere that it can be reached with either hand while shooting.

Homemade TQ’s are better than nothing and can be made from belts, scarves, bandanas, etc. Use a stick or some object to cinch the TQ down. I might add that expedient TQs have a very high failure rate due to functionality issues such as not being able to tighten enough to stop a major bleed totally. The TQ material needs to be at least 1” wide to be effective. Never remove a TQ once put in place. If a second TQ is necessary, make sure to place it proximal to the first TQ and leave them both in place. Make sure that clothing is not bunched up under the TQ that will allow circulation to continue due to crinkling of the tissue. Put date and time somewhere on the patient after TQ application to allow emergency room staff the knowledge of the approximate amount of time the TQ has been in place. Never cover a TQ with anything so that all EMS and ER personnel can visually see the intervention at all times. Lastly, always check any and all interventions performed after moving your patient, before, and during transport. I suggest purchasing a small blowout kit to be worn on your belt while performing any shooting sports. I will cover blow out kits in next month’s article in detail.

Well, this wraps it up for this month’s article.  I look forward to talking about blowout kits next month. Until then, happy shooting, lead by example, and teach firearms safety to your loved ones. Lead from the front by practicing what you preach. From the frontlines, where democracy never sleeps, this is “Doc” McBryde, and I’m Oscar Mike.

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