Active Shooter Response Session 6: Emergency Medicine

So no active shooter response course would be complete without talking about one of the most important aspects of the immediate aftermath of the spree killing. Whether you've stopped the bad guy, whether you've gotten away and some of the people have been wounded, or whether the police have shown up and stopped the bad guy or the bad guy as often happens has committed suicide, there's going to be a medical aftermath. And the more prepared you are to deal with that medical aftermath, the more you'll be able to help not only yourself or people you care about, but anyone else in the environment as well. Now you may not carry a large medical kit like this around with you every day. But if you have a backpack, if you have a purse, if it's easy enough for you to stage one of these in your workplace, it's probably a really good idea.

I have several kits like this. This one happens to come out of my vehicle. This is one that I take out on the range. There's one very similar to this that I would have out on the range. And if I had a regular place of business and office I would put one of these in there as well.

And the things that are in here can be carried in a much smaller package, whether it's an ankle kit or a smaller bag that would fit in a purse or more easily in a briefcase. The things that are in here are important. Understanding how to use them of course, is even more important. If you think about it, if you know how to use these things, you can improvise these things just like you can improvise a defensive tool. You can improvise some of the medical equipment as well.

But if you don't know how to use them and you have them, you may just actually do more harm than good. And I've heard people say that they like to carry emergency medical gear just in case emergency responders need it in the aftermath of a vehicle, a natural disaster or a spree killing. But I'll tell you, if you're gonna bother to spend the money and take the time and effort to carry this stuff around, you also should absolutely consider a much more thorough course in emergency medicine. But I do wanna take some time to go over the basics of the fundamental items that we have inside of this kit. The first fundamental item that we have is a pressure dressing or compression bandage.

Now this particular bandage is called a modular bandage. It's very capable of doing a lot of different things. And I want you to take a close look from one of our medical instructors, Caleb Causey of Lone Star Medics on exactly how you would use a pressure dressing after an emergency situation. Now we're gonna talk about blood claws, or assessing our patient. And there's a very specific order that we're going to do that.

So let's put this into a scenario. We're with our family and a loved one is injured and we don't know exactly what happened to them but we know we've neutralized the threat, the scene is secure for right now, but we're gonna maintain their situation awareness and keep our head on a swivel. But now we're gonna identify what's going on with the patient. The way we can do that is one, our general appearance or the general appearance of the patient. How do they look to you?

Do they look sick? Well, are they up talking to you and speaking to you? Or are they laying on the floor unconscious? There's a little clues that'll give us an idea of what level or what extent the injury really is. So to perform a blood claw, we've got our patient here.

We don't know what's wrong with them, but they're unconscious. We've already checked to see if they're awake. Buddy are you okay? The patient is unresponsive. We're gonna go ahead and call 911 at this point, call 911.

And we'll talk about that in a moment. Then we're gonna check, start at the head. We're gonna check and what we're looking for is any blood or crepitus or anything squishy, anything that's abnormal. So we start at the back of the head, every time our hands come off the patient we're gonna look. We don't see anything in the back of the head, the top of the head, the side.

And now we come down, look at the face. We don't have to claw their face. We don't want to cause any further injury but we can look at it. If we can open their mouth a bit, see if they have any loose teeth or if there's anything in their airway or their mouth that's obstructing the airway. We can go ahead and attempt to remove it.

And also if they have dentures. Well remember, some of our family members have dentures. And if we have those, and if they're in the way you gotta remove those as well. We've checked the front of the face, we're gonna check the back of the neck, the side and the front of the neck, and then with a claw like motion. And that's what I mean by blood claw.

We're actually gonna make our fingers claw up like a bear, and actually overlays our thumbs and claw away from the head down to the hips. Look for any blood. As we're clawing we're also looking for any gunshot wounds or any holes in the clothing. And gunshot wounds are not always this huge gaping hole in clothing. They may be the size of a buttonhole.

And that's what we're trying to find, not just holding the clothing, but also holding the patient. So as we claw down, we check nothing, nothing there. We're gonna check deep up in the armpits claw down to the hips. Look there, there's nothing. Now we need to check the back.

So we'll throw this shoulder out of the way. We'll roll them towards us. Check the back all the way down to the rear end, and check the other side down to the rear end. There's no bleeding or we haven't found anything yet. We'll roll them back.

Now we're gonna check the hips and the top of the leg as we come down. I notice, hey I've got something wet or really moist right here. Something's out of whack, something's abnormal. So I need to investigate further. And as I look, yeah well I didn't notice earlier because they hadn't bled.

Maybe they didn't bleed out that much or there wasn't a lot of blood. Now I see it. Hey, I did find one little hole here. Well, when we need to investigate this further, all right? But if they're bleeding and let's say we can see a lot of bleeding.

Our first line of defense as we learned earlier is a tourniquet. So we're gonna go and deploy a tourniquet. Take up as much as that slack as we can I've got high up on the leg as possible and I'm gonna turn it until all the bleeding is controlled. But for training today, we're just gonna turn it one or two times for our patient here. And then be sure you date and time the tourniquet.

Now, if they get a tourniquet, they go ahead and get a pressure dressing. So now we're gonna deploy the pressure dressing. The way we do this is well actually hold the dressing itself and put it directly over to that wound. We've got a little Velcro here that we can undo, if we really think we're gonna need it. And then we're simply gonna wrap the leg as we're applying the pressure.

Now, if you ever seen those NFL trainers when they're taping up somebody's ankle, they don't pull this the tape or that ACE wrap way out here. They let it come out of their hands. They let the wrap itself pull out of their hands. So be sure you keep this choked up close and we're gonna wrap once over that pressure cup. And as little pearl of wisdom, if you want just a little extra oomph into it, give it a few twists here, directly over that.

And now you're gonna cover up the top and bottom edges of the dressing. Keeping it nice and snug. Now, we've got these barbed fish hook looking deals and that's what we're gonna actually attach and, on either sides here to anchor that pressure dressing. Now that should control the bleeding from this gunshot wound. Okay, the next thing we're gonna talk about is the tourniquet.

Now tourniquets have absolutely become one of the most talked about medical items in recent history. It used to be kind of a verboten thing, or an extreme emergency austere environment. You're out in the wilderness. you have to use a tourniquet, you have no option, kind of a thing. I know that's how I was introduced to them during the cub scout era of my training.

But we've learned very much empirically from a lot of different unfortunate events including a lot of combat experience overseas that tourniquets absolutely save lives. Now, the fact is there has been a lot of research lately about the types of wounds that people sustained during spree killer events and active shooter events being very different from the types of wounds that people are likely to get in a combat environment. In a combat environment where rounds are being launched in a general direction or at a group of people quite often from extended distances or from behind cover, or at people who are keeping their torsos behind cover or military soldiers who are having torso protected by plate carriers or other body armor. We see a lot of extremity wounds, and the tourniquet of course, is the king of taking care of an extremity wound. If I'm squirting blood out of my arm or my leg and I can apply this tourniquet properly, it's gonna stop that blood loss and allow me to be transported to a professional medical care and be saved.

What we see in active shooters is many more close quarters torso wounds and close quarters head wounds. And the idea of keeping someone breathing becomes as important as keeping the blood inside of the person. Of course, you keep the blood inside of the wound but the person isn't breathing, they can't get air in and they can't oxygenate that blood. It really doesn't mean anything. So things like keeping airways open become even more important, but these are advanced medical skills that the average person isn't likely to have.

Can you learn them? Absolutely. Can you have the equipment that will help? For sure. But we still want to be prepared for that most common of injuries in the combative realm, the extremity injury that has an extreme amount of blood loss that absolutely could cause death.

And using a tourniquet and carrying a tourniquet is relatively simple. Let's take a look at one of the episodes of SWAT Magazine TV that I did years ago that still has some very valid information on the different types of tourniquets that you should be choosing from and a simple look at how to use them. We're gonna talk about some tourniquets real quick and how some of the tourniquets can apply in different situations. The proper use and application of a tourniquet. How many of you are familiar with tourniquet use?

Anybody ever used a tourniquet in real life? You have, okay. And you know, how much, how stressful that can actually be . Absolutely. So just like when you're doing, when you're practising with your firearm, you need to practise these tourniquets as well.

And the good thing is you can practise with a minimal problem, and no lack of, no risk of injury to yourself. But just like anything, long-term potentiation is the key. So in the tourniquets we're gonna talk about is the the SOF-T, the SWAT-T that's a special or the stretch wrap and tuck tourniquet. And we also have the NATO tourniquet here. And you can even look at, believe it or not, a stick and a couple of carets.

This can be an improvised tourniquet. You don't have to have anything that's a store ball because you may be in a situation where you may not have anything on you. I do recommend people carrying tourniquets especially with the latest shootings have been occurring in public settings. With the combat application look, this is one of the most wildly filled of tourniquets in the military right now, and the combat theaters. And it's been used with a fair degree of success.

They had over 865 applications of tourniquets back in 2008. And there were absolutely no limbs lost to tourniquet application. So they're pretty high success rate right there. And with about an 87% survivability rate, that speaks pretty highly. We've seen a paradigm shift in tourniquet use, we wanna make sure that tourniquets put on first because combat injuries, rapid bleeding out from wounds.

You can lose a over liter of blood in less than a minute . Okay. Go ahead and put up on your arm there. We say you're using your non-dominant arm, your reaction arm. Get that thing cinched down.

Okay? Okay. Squeeze yourself just the same here. All right, this is good right here. What you can do is you can bring that around.

That's fine, but what you've done you've got that Velcro close right there. Then what you want to start doing is turning that windlass. All right now, you don't have to crank down so tight you shut all your blood flow off and that's gonna be pretty painful. All right. So what we're gonna do is we're gonna do a scenario where you're having a active shooter situation and you're gonna engage the threat and you get hit in your non-dominant hand or what we call the reaction hand, and you remain you continue to fire, neutralize the threat.

And then what I want you to do is safe and holster your weapon, get behind cover and apply a tourniquet. Okay, we're gonna do a dry run of this first. So let's go ahead and get your weapons. We're concerned about time because the time the tourniquet's applied that tissue is without oxygen. And tissue time equals tissue, okay?

The next piece of equipment we're gonna talk about is sort of a miracle of the modern era. Over the last couple of decades, hemostatic agents have been developed that will help you promote clotting to a lot of different types of wounds underneath of a presser dressing. And in the absence of a tourniquet or inept situation where a tourniquet isn't going to be appropriate. Of course, the tourniquet and the pressure dressing could be used together with the hemostatic agent. In this case, this is gauze that's been packed with a product called quick clot.

And this hemostatic agent is packed into a wound. How you pack it can be very specific. And again, just like any other hands-on skill it's probably a good idea for you to get professional training. But I happen to do a clip for personal defense network relatively recently that talked about how you can very cheaply and easily practise packing a wound. You want to make sure that you get this gauze down into the wound and pack it as tight as possible to promote clotting and stopping the blood flow, not just forming a clot on the surface with blood loss internally still occurring.

Take a look at this video clip. You might've heard people talk about packing a wound in regard to putting a clean gauze or a hemostatic agent impregnated gauze or sponge down into a wound, particularly a gunshot wound that we talk about in the training environment or in the real world self-defense environment and not knowing exactly what they were talking about. Even if you do understand what they're talking about, you may never practise this packing of a wound. And it's actually something that you should try. And as really easy way to do it with a clenched fist.

And what I've got here is some Z Pak dressing. This is obviously just some sterile wound packing. This doesn't have any hemostatic agent which can be much more expensive to open up and train with. So I'm just gonna show you the technique here that you can use to pack the wound. When we talk about packing a wound, we aren't just simply talking about stuffing a little gauze in there and calling it good.

We really want to get as much of this material into the wound as possible and make it as hard as possible inside for blood to get out. When the gauze catches and the packing material catches the blood, especially if there's a hemostatic agent there it's gonna promote clotting and actually give you more pressure inside of the wound to keep that blood from leaking out of that vessel, that artery is probably what we're talking about, or any other vessels that are cut up in there. So what I'm simply gonna do is clench my fist down and just start to work this gauze into that clenched fist. I can do that with my finger. I can do it with my thumb.

One thing that you'll hear people talk about is packing in all directions, not just stuffing down, always curling to one side or the other, but making sure you're pushing into a lot of different directions. So we're pushing this in, again I can pack with a thumb. I can pack with the finger and my fist is still clenched. I'm still holding this very, very tightly as I push in, trying to fill all the nooks and crannies between my fingers, inside the knuckles pushing in. And this is something you can see I'm exerting some effort here.

That's really what we wanna do. We want this to be very hard inside of the wound packing as much material as we can in there. And you can see I'm creating space by hitting different angles, pushing in in a star pattern or pushing in in a circular pattern, maybe opposite and then crossing as I'm packing this wound, packing this material down in. Again, to stop the blood to get as much pressure as we can inside so that the blood isn't coming out. Continuing to pack, when it really starts to get hard at the top, you can see I'm still clenching my fist closed here.

Not really much movement on the fingers, and let's take a look. That's pretty good. That's a lot of material packed in there. And obviously we still have some material left larger wound we might be able to get more into it. But as I open up my fist, you're gonna see just how much material was inside of that fully clenched fist.

So packing a wound doesn't just mean simply covering up the top and hoping that's good enough and maybe wrapping around or putting a bandage over it. We really wanna stuff as much material as we can into the wound to create that clot, to create the area for the blood to stop coming out of the body, stay in and push against all of those torn and open vessels on the inside of the wound. Practising the pack of wound is an important part of your emergency trauma response, especially to a gunshot wound. The last piece of equipment that I keep in my medical kits for emergencies on the range or for other puncture or extreme trauma type wounds is a chest seal. And I mentioned earlier that airway issues and continuing breathing becomes incredibly important in the immediate aftermath of a spree killer situation because people are being targeted without body armor and in relatively close quarters.

So getting hits into the body or into the airway, the neck or the face are absolutely much easier than they are in a typical military combat environment. And that makes dealing with those chest wounds, chest wound that may have created holes where air is in and out inappropriately. We wanna make sure that those are dealt with appropriately. And how you do that is with a chest seal or with an improvisation of a chest seal that can be done with anything that will occlude the air from coming in and out of the body where it shouldn't be. Caleb Causey again is who we're gonna go to on this one.

But we're gonna go to one of the DVDs that we produced a couple of years ago. And we're gonna look at how to apply a chest seal to a wound that air is coming in and out of when we want it to be coming in and out of the nose or mouth. So our threat's been neutralized, and our patient here is having some difficulty breathing but we're not entirely sure what's going on. We're gonna go ahead and perform the blood claw as we've already done it. I'm gonna start at the back of the head.

Look, there's nothing there, here the back of the neck, nothing. And I'm gonna check this side of the torso and then I check this side. And as I do, I notice hey, there's something here. There's a hole here. So I need to investigate this further.

The easiest way to do that, is to come up here, and see what we have. And it looks like we've got some kind of chest wound here, some penetrating trauma inside the rib cage. So the best option for right now is to make this an airtight, watertight seal. We can take out our halo seal, simply pull one of these stickers off, and put it directly over this and try to smooth this out and get it as airtight, watertight as we possibly can. We've got that.

Now we need to check and make sure there's no further injuries on the back for as an exit. So we'll roll the patient, we'll look. Nothing, nothing there. We'll roll them back. So that looks like it's our only wound.

Looks like it's pretty airtight, watertight all the way around. We're gonna go ahead and continue our rest of our patient assessment. Feeling for anything abnormal, any holes or any crepitus or any bones poking out. Nothing there. So I finished my assessment on the patient.

I didn't find any further injuries or illnesses. So let's talk about this chest injury. What's going on in the body when we get a gunshot wound to the chest or anywhere the thoracic region meaning anywhere you have ribs and your rib cage. There's a positive and negative pressure system. So think of your chest wall or your chest as the container, and on the inside you have two sponge like balloons, your left and right lung.

What happens is that bullet enters through the chest wall. Okay, the wall itself, creates a hole there. Then it goes into the lung and let's say it just gets lodged in there. So that bullet's lodged somewhere in that lung. It's also created another hole in the lung tissue itself.

And lung tissue is very frothy, very vascular, very sexy, pink, spongy, like material. It's also very fragile. So we've got two holes technically, we've got one on the chest wall. We've got a hole also on the lung. Well, we can fix the hole on the chest wall simply by putting the chest seal on there.

Making it airtight, watertight as we've done. Now the problem is, we've got this hole still inside the lung, and it's leaking air. Every time we breathe in our diaphragm expands, we take it breath in, and the air goes down into our wind pipe and down into our lungs, and actually will leak out of that hole. So when it leaks out of that hole it builds up on pressure inside the chest wall. Now that doesn't sound too bad until after a while it starts creating enough pressure on the weaker lung, the one with the hole and the bullet in it.

And it'll actually build up enough pressure and collapse that beautiful lung, and will collapse and start making it harder and harder to breathe at the same time. When that starts happening it's gonna start pushing stuff over like the heart and it's gonna start making the lungs, heart. The other lung, the healthy one, work twice as hard than it's normally supposed to. Along with the heart's gonna accelerate a lot more, and the patient's gonna have a hard time breathing. So the only way we can fix that is through surgery which we can't do here or with a chest tube which we're definitely not gonna do out here in the field.

So with that chest seal over the wall we've solved that problem to really alleviate the problem with the tension pneumothorax that we developed now. And that's what it is. We've got the lung tissue being collapsed over here and all that pressure built up. We simply peel this up and burp it. And it'll look like this.

We'll simply peel this back, and you'll hear air escape, and you'll hear this, you'll hear the air escape. And then you'll simply cover it back up and make sure it's airtight, watertight again. When you do that, the patient probably will look at you and thank you for that. They'll say, thank you. And they'll actually be able to breathe then.

So let them have a few good breaths. Let the air escape, close it back up, make sure all the sides are taped up and you're good to go. If you've got the rustle chest seal, or the one with the valve, then you don't have to burp it because it already has that one way valve that allows the air to burp. But the halo seal is a really good chest seal for that option. So just to recap what we've done.

We started doing the blood claw. We found this injury here, the hole in the chest, in the rib cage. So we immediately exposed patient. We identify it, we deployed our halo seal, make sure it's airtight, watertight, and then continue the rest of our assessment. Now, some people may ask well, if it's bleeding do we apply direct pressure and put our hands over their gloved hand, over the patient?

Well, not necessarily. Chest wounds may or may not bleed a lot, but we're not worried about the bleeding so much as we are the air escaping or getting into it. So get that chest seal on there. Airtight, watertight, make sure it's on there. Nice and snug.

The good thing, another thing about these halo chest seals is no matter if the patient does have excessive blood or sweaty or a lot of hair, that glue on there is really, really strong and really adhesive. So it'll still stick on there. You don't have to worry about shaving the patient first or wiping bone dry. You can just keep on with what you got. And then don't forget to go ahead and finish your rest of your patient assessment.

Now that we've looked at how to use the most common and important emergency medical items that you should have with you if you bothered to carry emergency medical equipment, or have a kit stage in your workplace, let's talk about what to do if you don't have that kit, if you don't have those pieces of equipment. How can we improvise them? Well, the first thing that we looked at was the pressure dressing. Of course, a pressure dressing is gauze with some kind of an elastic band, more like an ACE bandage that you also sometimes have a plastic cup with that you can actually apply direct pressure and wrap tightly around a wound to get that gauze to be as compact as possible against the body. Well, if we think about the gauze that's just cotton filler, right?

So we can take a t-shirt. We can take an outer garment, anything that will absorb, we can take tissues, we can take a towel from the restroom. We can take a tablecloth from the restaurant table. We can rip the drapes down off the windows. Anything that will absorb liquid can be used as a packing agent to put on top of the wound and press into the wound.

And then we can wrap a t-shirt, a sleeve of a jacket. We can wrap anything around it, tying that knot over the wound to put that pressure on just like the plastic cup or any of the specific wrapping techniques you may see in formal medical training using specific medical equipment. So telling someone to take off their t-shirt and put it over a wound, take off their belt and wrap it or take off their jacket or long sleeve shirt, or even cut off a pant leg to create any type of rope or a strap that we can use to create that pressure, that compression around the packing material. That's our improvised pressure dressing or compression bandage. And that's gonna be a way to stop the blood flow as quickly as possible using things that are obviously going to be in the environment.

The tourniquet's the next thing we wanna look at improvising. Certainly you can take the cord from a lamp. You can take that cord from the drapes that you rip down that create your packing material. And some cases you could use a belt. If you have a belt that's very easily compressed, a belt that's relatively thin and relatively easy to form around the body you could use that belt.

You can use any piece of rope or string. You could even cut the seam or the hemline around a shirt. This is a reinforced area. So if we cut that off that would be a reinforced area that we could pull tightly and wrap around the limb above the wound. And traditionally, we're talking now about pushing that tourniquet up high and tight against the torso to cut that blood flow off to the limb.

We don't have to worry necessarily about going three fingers or avoiding joints if we just go high and tight. So thinking about wrapping especially with an improvised tourniquet, one that isn't designed to be used in that way, something that you've just grabbed, that belt, that cord, that piece of rope that you happen to have lying around, using those items is gonna be even more important to make sure that we're staying away from the wound and away from the joints and just coming up high and tight towards the underarm, underneath the ball of the shoulder and attaching for any arm wound. On a leg wound, especially the improvised tourniquet we're gonna want to come close up to the crotch, come close up to the joint between the leg and the torso and cut off the blood flow as best we can. And as I looked down there, I'm reminded that most of us are gonna have shoelaces, or someone's gonna have shoelaces and they can make a great improvised tourniquet as well. It's always gonna be better to have medical equipment but if you don't have it then these improvisations will work.

Now we can't improvise a hemostatic agent. Of course, we can't magically have a chemical compound laying around that's gonna help us promote clotting. But we could absolutely improvise some kind of a chest seal if we needed to. Plastic bag, duct tape, maybe even any kind of a Vaseline or a cream to help seal that even better, any kind of an oily substance to seal the gaps around that piece of plastic, taking that tape, just holding that plastic bag over the wound to trap the air that's coming in and out. These are all things that could help keep the air flow going in and out of the mouth and the nose in a worst case scenario.

If you have the equipment, if you get familiar with the equipment, if you understand how to use the equipment, you're gonna be much better off. But if you have the knowledge of how the equipment's designed, how it works and how to use it, you may be able to improvise emergency medical equipment that could save yours or someone you care about's life in the aftermath of a spree killing event. This section of the course also comes with some supplemental downloads. I want you to go ahead and go through those supplemental articles and read as much as you can and as much as you can absorb about emergency medical care and emergency medical equipment. And I strongly encourage you to supplement this active shooter response course with specific study just on emergency medicine.