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The best medicine on any battlefield is fire superiority. That simple mantra, or some version of it, is written in just about every tactical medical manual and Tactical Combat Casualty Care course ever taught. And for good reason.  If you are unfortunate enough to be shot, the most important thing is to ensure that you are not shot again.  That means limiting your opponent’s ability to continue firing and limiting his mobility are your primary concerns.  The best way to do that is by returning effective fire to the opponent . . .

How do we increase the odds that we will shoot back when injured? We train for it. No, do not put on body armor and have a friend shoot you. For all of my drunken redneck friends, I say again, do not do that. Do, however, practice drawing and shooting from the ground, from on your back, side, and stomach. Practice drawing off hand and shooting with each hand.  Practice drawing and shooting while crawling. (Be ready for a humbling experience there. It is super awkward.) Video it all or have a friend watch you to see when you’ve swept the muzzle past your own body. Note I said when, not if. It’s going to happen.

Be aware, the ability to fire multiple shots on target from these positions may change your carry gun and caliber choice. Be open to that. If we look at Uniform Crime Reports and the National Crime Victimization Survey data, we can see that a large percentage of victims were struck prior to knowing they were under assault. Sure, there is a lesson in situational awareness there, but also a lesson in the reality that if you are in a gunfight, it is very possible that you will be the second one to fire, and the second one to get shot. Train and arm yourself for that.

So, to be crystal clear, even if you have been shot, especially if you have been shot, if you are still under threat, shoot. Keep shooting until you have stopped that threat. In my medical experience, the death of the attacker(s) is certain to stop the immediate threat.

I know what a lot of you are thinking … find cover first. No. Shoot back first. If you are wounded you are at a disadvantage. As you continue to bleed, you will get slower, weaker and dumber. Your uninjured opponent will not. Your opponent will be able to continue to aggress, having better and better chances to finish you off. You will not win the waiting game. Help will not arrive in time. Stop the threat.

After you have presented your weapon and returned fire, start moving. Some people can do both of these at the same time. Not very many can do both at the same time well when shot, but get moving. It is YOUR responsibility to get to cover. No one is going to rush out and grab you and drag you to safety, and you don’t want them to. That’s your job. And it’s your job to take the first steps in caring for your wounds once the threat is over.

That first step, if it is now safe to do so, is yelling for help. Get a buddy as fast as you can. Note I didn’t say “call 911”, that comes in just a minute. I said yell for help. If they are in earshot they can help you in time. If they aren’t, they probably can’t. Yell your heart out, but don’t waste time doing it, you’ve got more work to do.

Immediately, stop the bleeding. Here’s the mantra to remember, “Squeeze squeeze, squeeze until the red blood stops.” There is no substitute for pressure. It will very likely hurt. A lot. Yay for pain, cause that’s means tissue is still alive and you are conscious. Good job. Keep that up.

If the wound is in an extremity, any place on your arms or legs, and blood is steadily coming out of the wound, the first thing you should do is put on a tourniquet. If you don’t have one hold pressure until you can make one. Look online for how to make one … it’s pretty easy and not complicated at all. Practice doing it one handed. At this point, for gunshot wounds or similar penetrating trauma to an extremity, don’t even bother exposing the wound. Just put a tourniquet well above the injury and squeeze.

How hard do we squeeze? Until the red blood stops. That’s going to be much, much harder than you think. And be advised, I’ve had to use two or three tourniquets on leg injuries. If you have to do that, it’s ok, just keep applying them, each one above (closer to the heart) the last one.

How do you know when it’s enough? Say it all together please. Then tie, tape, ratchet strap, whatever it takes, to keep that tourniquet in place while you continue to provide aide for yourself. But secure it firmly and try to keep it raised above your heart.

For all of you who think that you will automatically lose that arm or leg because you put a tourniquet on, stop it. That’s not real. If you are CONUS you will almost certainly receive medical treatment before the two hours or more that it would take for permanent tissue damage to occur. I’ve had patients with tourniquets for over 10 hours without long-term tissue damage. (How to reduce a tourniquet is a skill that you should not try in the real world until you’ve had hands-on training by a qualified medical personnel.)

For your trauma kit, I would highly recommend the SOF Tourniquet with the metal bar. Never buy just one, always carry at least two. 

Now, if you don’t have a tourniquet or the wound is not on an arm or leg, you are going to have to apply pressure. Pressure is your friend. An absorbent pressure dressing is much preferred, but the pressure part is most important thing. Table napkins balled up and jammed like hell into an injury will hurt, but they also stop bleeding. You don’t care about sterility. You don’t even care about clean. You care about now.

Probably the best impromptu pressure dressing I’ve ever seen was a tennis ball pressed tight on top of a stab wound. There was no absorbent material at all applied. Just the dog’s tennis ball pressed so tight it was pretty much flat on the guy’s lower back. It stopped the bleeding surprisingly well and it was the first object within reach of the first aid provider when he saw the patient on the ground. Ideally, you would have one of the hemostatic agents currently on the market. If you can get them, get more than you think you will need, and whether you push or pour them into the wound, follow that with – you guessed it –  lots of pressure.

For your trauma kit, I recommend something like Quick Clot Combat Gauze. I’ve used it heavily and it works very well. And just tons of Kerlix.

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Unless you are qualified, knowledgeable, and experienced medical personnel, do not, at any time, ever remove a bandage or dressing. Ever. You don’t need to take it off if it hurts. You don’t need to take it off to see if it is bleeding. You don’t need to take it off to put another one on. If the bandage has blood coming out of it, put another one right on top of that one and apply more pressure. Keep on doing that. Until when? Until the red blood stops.

For self-aide there are some particularly challenging places to stop bleeding. Deep groin injuries can be extremely difficult to stop, and some thoracic trauma can be impossible in the field environment. The groin is best attended to by balling up something firm and shoving it in the crease of your leg, bringing your knee up to your chest and over, and then laying on it to use your leg as a lever to push the pressure dressing in harder. That’s if you don’t have help. If you have help, they should put their knee right there in that crease and lean on you will all their weight. It’s going to hurt. Again, yay pain.

The very deep thoracic trauma can sometimes, in the field by yourself, be treated with positioning and not much else. That is, if you are shot in your left chest, lay on your left side. On your right side if you are shot in the right side. It seems counterintuitive to some, but if your lungs are filling up with blood, it’s better to just lose one lung, and that’s the lung that’s already got a hole in it. So bandage it (both sides) and lay down on that side. It’s going to fill up with blood. It’s going to be hard to breath. Eventually, you are going to lose consciousness. But that will take a while and even then, you aren’t dead yet.

When do you call 911? As soon as you have squeezed until the red blood stops. Tourniquet – pressure dressing – position – 911. Don’t wait to reassess, or anything else. Ideally this should be within minutes of getting to safety. Listen to what they have to say, on speaker phone mode. Sit down or lay down and continue to reassess yourself for injuries while you talk to them but tell them what has happened and where you are and don’t move again. Leave the phone on speaker next to you as loud as you can make it go, even if you think you are done talking to them. Do not hang up.

At this point, you are on to secondary concerns. One of those is that if you are shot in the chest, you may very well have a sucking chest wound. How would you know? I’m sure it hurts like hell no matter what, and you are going to feel one lung short no matter what, but the key is that patients report increasing pressure and it gets harder and harder to breath.

Ideally, you would solve this with a purpose-built dressing with a one-way valve. If it’s a through-and-through wound, you are going to have to seal one side off entirely. If you have an actual valved chest seal, put it on the place you can see, and then tape the crap out of it if you can. If you don’t’ have one, any piece of plastic will do. But every once in a while, when the pressure builds up, crack the edge of it and breathe. It’s best if you breathe out completely before placing or replacing the seal, then attempt to breathe normally.

For your tauma kit, I prefer the Hyfin chest seal. I have not used the Halo but I’ve heard good things.  

Try not to move, but if you have to, you need splint up if you have an injured limb. Even if it’s not obviously broken, any injury to a bone needs to be splinted, or not only will it just hurt like the dickens, but shards of bone will act like razors inside of tissue, causing further damage. The only way to learn how to do that is to practice. There is no wrong way to splint, as long as it immobilizes the limb.  So give that a try when you aren’t shot.  It’s a fun game to play with your kids.

For your trauma kit, I highly recommend carrying at least two SAM splints as a minimum. 

The nice thing about applying care for yourself if you are shot is that you really don’t have many options. You aren’t likely going to be able to give yourself better airway access, you can’t give yourself CPR, and there are very few instances outside of a combat zone with a long evacuation time where you should even consider giving yourself an IV.

Having those few responsibilities means your decision tree is doesn’t branch too much, and you can just focus on those tasks that will have a big impact on your survivability.

Return fire to stop the threat. Seek cover. Yell for help. Treat bleeding. Call 911. Treat for sucking chest wound if required. Splint if required. Reassess your own injuries and situation. Stay on the phone with emergency personnel.

In my time as a medical care provider in the US as well as in the Army, I’ve seen literally hundreds of high energy penetrating trauma wounds caused by gunshots and blast injuries. The good news is that so many of them survived. My first article on TTAG was in response to a question about the wounding characteristics of different rounds. I concluded, based on seeing so many patients, that all common pistol rounds pretty much sucked for any kind of instant incapacitation, and that with qualified medical care, the vast majority of people shot lived. If you are one of those people, that’s good news for you.  It means that even if you are shot at close range with a large caliber pistol, you have a fighting chance to survive.  Most of the time, you can do something to improve that chance.  Get to work.

There are a few things you should try and keep with you, in your hunting bag, range bag, travel bag, vehicle and home, that will dramatically improve your survivability if you should have to treat yourself.  Those include a couple of tourniquets, bandages (preferably with a hemostatic agent) a chest seal, 2 SAM splints, and big roll of medical tape, and a bright small flashlight that will stay on even if you aren’t holding it.  There are a lot of other great things to have, but those are your minimums. 

For those of you who want to get into more medical training and would like a good guidebook, the Ranger Medic Handbook is the best single guide I’ve ever seen. For more in-depth reading, I would recommend the US Army’s Emergency War Surgery, now published completely online as well as my constant field companion, Tintinalli’s Emergency Medicine Manual.  

53 Responses to Combat Medic: The Work Really Starts Once You’re Shot

  1. I thought that I had a pretty good kit in the car. Now, not so much. Thanks for making me think.

  2. And here I am tying to pick out which bottle opener my AR should have adorned on its rail. Great write up Jon.

    • I was literally just looking at that lol. Its 3AM here and I am looking at my kit to make sure it includes the basics now! :O Gonna have to buy a serious IFAK.

  3. I’ve been out of AIT for 5 months and all my Whiskey school instructors seemed to prefer the Halo over the Hyfin. It’s the only chest seal we practiced with. Good thing is that the plastic backings for the adhesive seals can also be used as improvised occlusive dressings.

  4. Good article. I have the training per my job requirement, but I have never had to stop a penetrating injury…

    Which is a good thing.

  5. Great article; reminds me that I need to put another pack of Israeli Gauze in my range bag.

    But why no mention of iTClamps? Assuming some enterprising local company (hint, hint) can get them into the retail chain at a reasonable price, don’t they address a lot of issues better than just about anything else out there?

  6. I’ve heard good things about the QuikClot Combat Gauze, but the shelf life is *very* short.

    At 40 bucks a pop, how long after it expires is it still good for?

  7. It’s nice to see that the civilian world has caught up with the military on the subject of tourniquets. In my EMT class, we were instructed to apply TQ’s 2 inches above the wound, tie ’em down until the bleeding stopped, then continue assessment, slap on O2, package and ship.

    Surprisingly, the most push-back on TQ’s seems to come from older MD’s in the civilian world. They’re still dispensing the old bromides about TQ’s.

    Turns out, with a little bit of study, we can see where the “conventional wisdom” on TQ’s started: Back in WWI. Apparently, soldiers wounded would get a TQ put on, then it might take then 18 to 48 hours to make it to medical assistance. Then doctors started blaming the TQ’s for the loss of the limb… whilst ignoring the alternative, which would have been loss of life.

    In today’s civilian environment, even here in Wyoming with our long transport times, applying TQ’s is the SOP for extremity wounds where bleeding cannot be controlled by direct pressure and elevation.

    SAM splints: Wonderful invention. Be sure to have roller gauze to wrap around them to hold them in place, or have plenty of tape. Useful tip for patient comfort: If you’re applying a splint to someone else, try to mold the SAM splint to your arm/leg before you put it onto the patient and mold it into shape there. Molding it on the patient might cause horrible pain, whereas just tweeking the splint on the patient would cause less. Whenever splinting, check for sensation & pulse distal to the point of injury or fracture before and after applying the splint. If there was no sensation or pulse distal to the injury, note that and the time.

    SAM splints can even be used to make a makeshift C-collar.

    NB that you can lose major blood from broken bones, even if they are not open fractures. eg, A broken femur might cost an adult male 1 liter of blood loss internal to the thigh – it will balloon up in an ugly way in an hour or so. Broken femurs can be really painful without a traction splint. I don’t see any way that one could self-administer a traction splint for a femur, tho. A split pelvis (not as uncommon as you might think in rodeo country) might be a 1.5 liter fracture.

    Last note from my training: Write down the time of the application of the tourniquet or splint. Write it on the patient’s forehead (if treating someone else), write in on paper you can hand over to a RN/MD in the ER if you’re self-treating. Note the limb (right arm, left leg), the letters “TQ” and the time. You’d be surprised what happens in the ER when the doctors and RN’s start into the case. They suffer from human failures too, and they sometimes miss the issues on the extremities if there is a wound or issue in the core of the body. If you’ve got a sucking chest wound, they can tend to fixate on that and ignore your arm/leg for too long unless attention is called to it.

  8. Since the OP began with first ‘returning fire’ (too) please be as vocal and deliberate as the situation will allow when moving to assist someone who has been shot or blown up. They might be following rule #1 (see above) under the incredible fog of war, and you could be lying there next to them because they responded to you as though you were a secondary attack (if you can even get that close). Don’t use your medical / safety gear if the situation is still hot, as you might need it [and worse]. If you DO use – Replenish. If you DON”T use – Replace your nasty old stuff.

  9. Excellent timely article.
    We take for granted that we should carry a firearm when we can for personal protection but don’t often think about the emergency medical aftermath of a shooting – or all of the other common risks of injury we face every day.

    My go-bag with my motorcycle includes a CAT tourniquet and two “Israeli Bandage” elastic pressure bandages. And if I am wearing cargo pants or shorts I’ll tuck one Israeli bandage in a pocket around town. Good compression dressing and can serve as a tourniquet in a pinch.

  10. As an Active Paramedic, Bravo, very spot on!
    In a 1st aid bag I would add 1 more item, very small but useful. A “Dumb-Phone” Cell phone. In the US it does not need to be associated with or activated on any plan, it can still call 911. I say Dumb-Phone, because they last forever with when turned off, you only need to remember to charge it occasionally. But in the event of said event you end up shot you may drop your phone, break it if/when you fall. Or have surrendered it as a Ruse-de-gure. Having a backup way to call 911 is pretty smart…

    • Not just the US! ALL GSM/UMTS/LTE phones (almost all phones in Europe and most phones in the US) must be able to reach emergency services, the phone can not have a locking screen that prevents an emergency dialer (hence on the iPhone their is an emergency option even when its locked), no SIM card needed, even if you see “no service” you could easily pick up 5×5 on another provider. I’ve seen this happen before in rural Adirondak Mountains as well as during outages.

      Dial 911 in the US but if you are abroad and you do not know the emergency number for sure dial 112, that is the universal emergency number for GSM worldwide and it will direct you to emergency services. Very useful since I’ve been out of the US before and thought “wait, I don’t know the emergency number here! but I know 112!”

  11. Great post JWT. Thanks for including some supplemental reading material as well, it’s always nice to have a hard copy to scribble on.

    What are your thoughts on the various pre-packed IFAKs on the market now (e.g. Dark Angel Medical, NAR, Tactical Medical Solutions, and so on)? I have one and know how to use the components, but I have a lot of friends who shoot and don’t want to take the time to learn first aid. This is in spite of the fact that most of the places we shoot outdoors are minimum 20 minutes from EMS care if not closer to an hour. Are these kits too much for those folks?

  12. Good article.

    Here’s another tip: Do not apply a tourniquet to a neck wound. Just don’t do it.

    • “Here’s another tip: Do not apply a tourniquet to a neck wound.”

      Don’t be too hasty.

      It depends on *who* has the wound that may very well benefit from that…

      *cough*

      🙂

  13. Ok… This is probably the best combat medicine primer I have ever read. As someone who has actually pulled a bullet out of his own ass (metaphorically speaking) I would strongly recommend turning this into a video lecture.

  14. I love all the folks I’ve encountered in training (and overseas) who rubberband a CAT on their kit and have no access to anything else (no IFAK, dressings, etc.).

    A CAT does nothing for you if the GSW is to the chest.

    • Also a good argument for standardized placement of the field dressing on personal equipment. You want to use the casualties dressing first, and it helps if you know where it is at. A pouch with a cross on it is handy.

  15. Great article. I’ve been wanting to create a first aid bag to take to the range and this gives me some guidance on what to put in it. Where does a civilian go to buy this stuff? It’s not on the first aid aisle of the local grocery store.

  16. Spot on JWT. Great distillation of knowledge that everyone should have, and an entertaining read to boot. You definitely didn’t plagiarize that from Tintinalli.
    It seems a bit beyond the scope of the article, but if people are looking to add to their personal med kits beyond your excellent recommendations, I’d add a nasopharyngeal airway (at least if you’re going to be 30+ minutes from EMS.). Obviously not for self-application.

  17. Great article JWT, I learned quite a bit.

    Would you ever be interested in providing a short write up on suggested supplies for a couple of different levels of medical/first aid kits? For example a range bag sized one, a vehicle sized one, and one for the house that has all the bells and whistles.

    I have attempted in the past to assemble my own kit or start off of a prebuilt kit but I just don’t really know what I might be missing or what I should have more of or what I should scrap, etc. I figured a man of your experience could help there.

    Of course I think part of the answer to this questions is get first aid training; that will help you start to figure out what you need and how much of it as well as how to use it. In this category, I have some first aid training from my days as a boyscout (first aid and lifesaving merit badges) but I fully believe most of it would now be considered out of date info. For example, tourniquets were strongly discouraged in all the manuals at the time.

    At any rate, thanks again for the article!

    • I have found that basic first aid courses cover very little outside of basic pressure on wounds, a sentence or two on tourniquets, and cpr/heimlic maneuvers. Lifeguard training was better, but didn’t get I to sucking chest wounds or gunshots specifically. There was more info on escalating care, ltourniquets, and a lot on back boarding, but always in the context of getting paramedics there asap.

      Ultimately I’ve built my kits by starting with a cvs first aid kit that includes cpr shields, and added torniquets and at least a field expedient method of making a chest seal, along with other methods to stop bleeding(quick clot, tampons, pads, etc) and a whole mess olarger bandages/gauze, and Otc meds to handle allergic reactions, pain, burns, low blood sugar, and colds. It end up being roughly the size of a 50 cal ammo can, an I keep it my vehicles. Each kit has a smaller pouch for the essentials to preserve life from severe bleeding/sucking chest wound/splint (use duct tape and improvised splint materials like sticks to keep things compact) and Ppe like gloves. That way I can grab it from the kit and carry it with me while hunting, doing chainsaw work, or shooting.

      The best advice I can give you is read up, identify the biggest threats to life, the ones that will kill you quickly (hint: bleeding, breathing, heart) , and equip as best as possible to stabilize those injuries enough to get back to your vehicle or an ambulance. Keep that kit on you. Keep the rest relatively nearby.

  18. Good article. My only meager contribution is to recommend that you have your vaccinations up to date. Tetanus and Hepatitis B should do it.

    Tetanus comes in two flavors: Td for Tetanus and Diphtheria, and Tdap for those + Pertussis (aka whooping cough). Hep B is a two or three shot sequence spread out over maybe six weeks, to be effective. Something like that, so you’d want that ahead of time. Consult your own qualified medical professional, which I am not.

    There are other vaccines available, of course, but advised only if the risk of exposure is realistic. You’re not going to get Typhus or Rabies down at the range, for example. Now, kicking down doors in downtown Kandahar? Who knows? Know before you go, and wear gloves.

  19. This is one of my most favorite Truth About Guns posts ever. On par with Jeremy S’s muzzle shootouts. Thanks JWT!

  20. And to think I walked past all that equipment at the gun show. I have been building an arsenal for a little over a year now, and never even thought about ME getting shot. This article completely changed my view on my kit. I am almost, completely, unprepared.. Except for the “RETURN FIRE” part. Thanks a lot. Hope I never need any of this kit, but I’ll get it and find a class.

  21. great article! and timely, as i’ve been looking into a small med kit for my edc. what do you think of the SWAT-T? looks very good product that definitely follows the KISS method and is a multitasker… also very inexpensive at $10. http://www.swattourniquet.com/

    • I’ve never used the SWAT in the real world but I have worked with it in training. It seems like it wouldn’t squeeze hard enough for some leg wounds. That’s why I recommended the metal bar above. So much pressure is required for some leg injuries that I have broken the plastic one on the CAT.

  22. Great article. Thanks. I have most of this equipment but am deficient with the tourniquets and I also need practice using the gear. I’ve bookmarked this post for future study.

  23. I’m a recently retired 18D (SF Medic), and I really like the Olaes Bandage as your go-to packaged pressure dressing. Israeli dressings are great, but the Olaes is just a little bit better. Never used it on a person, but used it during refresher training back at Bragg and really, really like it. The whole “eye cup” part of it is rather “whatever,” but that particular piece really helps put the pressure on when used as a bandage on live, bleeding tissue. Just prior to retirement I made sure to grab a bunch of the Olaes Bandages to stock up my assorted medkits for here and there

  24. In regards to contacting emergency services, in the US and worldwide with any GSM/3G/LTE phone it has to be able to dial 911 without a SIM card or service plan, even if the phone is locked! If you are ever out of country remember that 112 is the universal emergency number! It will automatically redirect to whatever emergency number that country uses, it works in the US as well. Bring an old dumb phone and keep it off and the battery will last a long time!

  25. Great article! As an AEMT, I’ve been trained for a broad range of medical emergencies, but these are the ones you don’t always see day-to-day. It pays to prepare, think about the “what-ifs”, and have a plan.

  26. @jwtaylor this is a well-written, exciting article. Fun to read. It made me feel like I had been placed in the midst of an active battlefield. Extremely useful information. Hopefully I’ll never have to utilize it. But if I do, you may have helped saved a life without even being present.

    Thanks.

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