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Being shot and having to treat yourself is not ideal. I went over the basics of what to do if you are shot in a previous TTAG post. The nice thing about treating yourself is that you don’t have many options, so you can focus on doing those few things really well. In this post, we’ll go over what to do if someone else is shot. I would recommend reading that first post for some specific treatment methods that we will gloss over here . . .

First things first, just like when you are shot, if someone else is shot, your first order of work should be ending the threat. If the threat is ongoing, that means returning fire. Like we said the last article, the best medicine on any battlefield is fire superiority. You must limit the opponent’s ability to fire and maneuver. But once that’s done, and you and the victim(s) are safe, it’s time to get to work. And this time you have a lot more options, and you may have a lot more work to do.

Before we get into how to treat a gun shot wound (GSW), we have to get into deciding who gets treated first. Obviously, if there is only one person shot, just get right on that. But what if there is more than one? Weather the attacker intended to shoot one person or not, there are often multiple victims. Getting to the right ones first is a skill set that only experience can really master, but there are some techniques that will really help.

The overriding rule of triage is that you help those that are in need of assistance and have the best chance of survival if you provide that assistance. That sounds simple. But emotionally, mentally, that can lead to some extremely difficult decisions.

If you think getting shot or blown up and driving on with the mission makes you hard, it does, but not compared to the decisions you have to make in triage. Trust me, I’ve done both. And you will be able to make those decisions as well, and people will be better for it that you did.

What kind of decisions? Well, for instance, I have had to step over breathing children and delay their care, knowing it would result in their death, to work on a conscious adult. I did that, more than once, because I had a better chance of saving that adult’s life than I did the child’s. Nothing will get to you like dragging a breathing child away to die alone while you work on someone else. But you may have to do that, or both the adult and the child will die.

And note, you aren’t trying to help the largest number of people — you are trying to help the people that you can do something about, to save life, limb, and eyesight. I have, in my career, had an event where I had six severe traumatic patients. I knew that if I did everything right, everything just perfectly, five of them would die. And they would die because I would have to ignore them to save the one I thought I could do something about. So just understand that those decisions will have to be made, and very quickly, and correctly, or everybody suffers, and more will die. The worst possible thing is to wait. Waiting is murder.

Also, once the threat is gone, everyone wounded is a patient. Everyone. That includes the aggressor. Yup, you have to treat the shooter. This isn’t a philosophical debate. If they are no longer a threat and they are wounded, they are a patient and you have to treat them to the best of your ability, and that means triaging them appropriately. I have treated the enemy before myself. Try and avoid that scenario.

There are many methods to triage, but here is an easy and effective one; once the scene is safe, stand up, use your loud grownup voice, and say “My name is (___).  People have been shot and I’m here to help. If you can hear the sound of my voice, get up and come to me.” Give that just barely half a minute. The people that can get up and start to make it to you are your second priority.

The next thing you say is, “Ok, if you can hear the sound of my voice, raise your hand and yell, let me know where you are”.  Those people are your first priority. Get to them right away. Because if they are conscious but can’t move, they are in bad shape, but not so bad you can’t do something about it.

The people who could not respond to you in any way are your last priority. You treat the responsive but immobile first, then the mobile, then the unresponsive. And you are only treating them for life, limb, and eyesight. You treat everyone you have time to treat and none you don’t.

If you are shot, treat yourself first, then get to work on everyone else. If that’s just one other person, great. But it might not be.  Unlike before when it was just you getting shot, if there is anyone else conscious there, have them call 911 immediately. Even if that is the victim. Getting the GSW victim to call 911 is a very good thing. It keeps them engaged and conscious, and frees you to work. If there is no one else conscious, but you have more than one victim, call 911 now. The same rules for putting the phone on speaker phone mode apply, and never turn it off.

So, the scene is safe and you have sorted the victims. Breath deep and smile, the hardest work is done. I mean it. Force yourself to take a deep breath. Force yourself to smile. The most important vital sign in any casualty event is YOUR pulse. So take a breath and get yours down a bit.

If you have help, instruct them to start helping other people, but be willing to call them over if you need them. Until there is a more competent medical provider there, you are in charge of helping the victims.

The first thing you are looking for is bleeding. The way we do that is by asking people where they are shot, looking, and performing a rapid blood sweep. There is no need to take clothes off or expose the wound at this point. Wipe your hands off, put them on the patient, and then look at your hands again. If there is blood, check that area out and get to work. If there is no blood, move to the next part of the patient, checking your hands each time. It does no good to check the whole patient and then look at your hands – you won’t know where the blood came from.

Just like before, your go-to care for a GSW to an extremity is the tourniquet. If you need to make one, get someone else to hold pressure while you make it and apply it. But get on that fast because it is relatively easy to remedy and will save a life quickly. By the way, a patient with a GSW to one arm can dial 911 with the other.

Injuries to the torso will require a dressing and pressure. Expose only the wound area you have to, but press down on that injury. Yes, you can stick your fingers inside of them to put pressure on the wound. No, do not fish around. As in my earlier article, hemostatic agents such as QuickClot Guaze are preferred, but not required. Get that dressing on, pressed as hard as you have to, and tape it all down. How do we know when the bleeding is controlled and it’s ok to move on to something else?  Squeeze, squeeze, squeeze until the red blood stops.

Just like before, a patient with penetrating trauma to the upper torso may have a sucking chest wound. If the patient is conscious, they will tell you that it’s getting harder to breathe. If they are unconscious and unable to tell you that, you will eventually see the uneven rise and fall of their chest. There are a few good telltale signs, but if you haven’t seen them before you will likely miss them. So the general rule for you, if you are not medically trained, is to treat any open chest wound as if it were a sucking chest wound. Refer to my previous article for treatment.

Some of you wise guys may be asking about needle-chest-decompression. That’s where you shove a 14g needle into someone’s chest cavity to relieve the pressure.  Unless you have been extensively trained with this in a hands-on setting by a qualified medical provider, do not attempt this. The majority of trained first responders get this technique wrong in one way or another and many cause more harm than good.

In the worst case scenarios, I’ve had Combat Life Savers go under a rib instead of over it and cause more bleeding into the thoracic cavity. I’ve also seen patients that received a needle chest decompression that did not need one at all. And now they need a thoracotomy. Not ideal. Skip it unless you really know what you are doing.

As in my previous post, roll a patient with a thoracic GSW onto the side of the injury and make sure you treat any exit wound.  Patients with any facial trauma should be rolled onto their side, or at least have their head turned to the side. Do not put a pillow under a GSW patient’s head unless there is an injury to the spine and you need to keep it from moving. I have seen a patient killed from a good Samaritan putting a makeshift pillow under her head, cutting off the flow of air down her windpipe and choking her to death. Don’t do that.

Now we can move to the patient’s airway. For the vast majority of GSW patients, simple positioning will protect their airway. That is, unless they are shot in the face and have teeth and blood loose in their mouth, just sitting them upright or laying them on their side will be good enough. If they are shot in the face, you may have to perform a simple finger sweep of their mouth to get bone or teeth clear of their windpipe so that they can breathe well. Don’t just fish around. Look in first and see what’s wrong, then you can sweep a finger through their mouth to take out any obstructions you see. Positioning on their side is good for now if they are not fully conscious. Be aware, you will likely have to do this more than once.

As in the earlier article, we aren’t going to worry about putting in an IV. Even in most combat situations, we don’t do that anymore unless we know that it’s going to be hours before they receive comprehensive medical treatment. For most people, training time spent learning to give an IV is far better spent learning to stop bleeding in the first place.

If you only have one other patient, and they don’t have a pulse, control any bleeding and then move to CPR. There is no need to perform CPR if you cannot control bleeding, or if there is another patient you can help. You will perform CPR unless help arrives. If you do it right, you will be exhausted in a matter of minutes.

Treat all of the life-threatening injuries on one patient before moving to another.

Now is the time to splint up injuries, bandage eyes, and get patients out of the cold or extreme heat, and getting them ready for the ambulance or other transportation. Unless you are way out in the woods, there is no need for you to carry a patient. If the scene is safe and you find yourself picking someone up, you are doing it wrong. If you must move them for the sake of safety or to get them out of extremes, drag them there. I don’t care if they only weigh  50 lbs. and you are a big strapping man, unless they are an infant, drag them there, don’t carry them.

Now is the time to start reassessing your patient(s). Your biggest concern is still the bleeding, doing another complete blood sweep and making sure nothing has come loose and is bleeding again, or still. Check and see if it is time to relieve pressure on that chest seal. Talk to your patients constantly, and keep them involved in their own care. This reassessment, treatment, and assurance will continue until more help arrives.

Good medical gear really helps, but most kits have more things than you will need or know how to use. If you are on the range with other people, or you can throw a bag in your home or vehicle, I would recommend at least the following to treat others:

At least 4 tourniquets

At least 4 sets of Quick Clot Gauze, and at least 6 rolls of Kerlix.

At least 4 chest seals

At least 3 Sam Splints

And buy more medical tape than you ever thought you would need and a flashlight that you don’t have to hold down a button to keep on. That’s the minimum. Put it in any easy-to-get to bag. I prefer everything in clear zip lock bags and put it all in one big compartment.

As I wrote before, 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.

 

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35 Responses to Combat Medic: What To Do If Someone Else Is Shot

    • Celox doesnt create the heat that old QC did, Its just as gummy as QC though so the surgeon will hate you either way once the victim gets to the OR.

      Somebody did a study with pigs and GSW and Stab wounds where they used QC, Celox, standard bandage and one other coagulant product and they found the highest survival rate with the pigs and the highest rate of rebleed prevention was with Celox over all other methods.

  1. “Also, once the threat is gone, everyone wounded is a patient. Everyone. That includes the aggressor. Yup, you have to treat the shooter. “

    Wanna bet?

    I’ll slowly wave at them as I watch them bleed out.

    • Actually, and this in no way constitutes legal or medical advice, my understanding is once the shooter is no longer a threat, your duty is to treat the wounded. Now, obviously, per the priority of life theory, the shooter is the lowest on the chain. However, if there are no other wounded left to treat, you must then treat. JWT (or others with experience in this field), would you mind weighing in?

      • For the military there is no blurry line. If they are no longer a theat, they are patients. On the civilian legal system, I dont know and dont care. Because as far as I am concerned, if I failed to kill them outright and wounded them instead, they are patients.

        • Marines in the PTO might have had a different rendition. The HBO series The Pacific was more accurate than what you might think.

      • The thing I would be most worried about, in attempting to save the shooter, is that they end up having some medical complications. Then they sue you. Now you are twice the victim.

        Still I agree you have to try but, if there is any doubt about the priority, I’d place an innocent as a higher priority.

    • Ha! I’ll put a $20 on you, the second anything gets remotely difficult, making like George Costanza in that episode where he trampled a bunch of women and children at the birthday party when somebody yelled “fire”

      • I’m sorry you feel threatened by someone who doesn’t view every life as precious. Particularly those of someone who may have just tried to kill me.

        You should also learn the definition of hyperbole.

    • Yeah, I’m not treating a guy who just shot the place up. I’ve watched cops stand around waiting for medics, so I certainly have no duty to proved medical help (that I am in no way qualified to give) to some a-hole who needs to do the world a favor and just stop breathing.

      For anyone else I would do my best to keep them alive until someone who actually knows how to save their life shows up.

  2. I cant really see any punitive measures for not treating the shooter as a regular citizen. Especially if no one else is shot and you plug him and retreat a safe distance away to dial 911, I can’t see that being an issue.

    • I think even an off-duty EMS could probably get away with saying they weren’t sure if the guy was still a threat. That being said, the family of one of the North Hollywood Shootout(tm) guys successfully sued the city for not treating their scumbag brother in a timely fashion.

      • Fire/EMS people who are on duty have a duty to act under the law.

        A regular citizen? Not in the same category, even if they have EMT training. If you’re not on duty, you’re out from under the legal duty to act.

        This is what makes cops’ failure to act all the more galling. LEO’s have a nice, special carve-out in case law that allows them to stand around, waiting for the donut truck to arrive, doing jack-all. Fire/EMS people on duty? You’d better at least pretend to do your job.

  3. “Wipe your hands off, put them on the patient, and then look at your hands again. If there is blood, check that area out and get to work.”

    This doesn’t seem like a good idea without gloves. What is the alternative if we do not have them? Unprotected exposure to blood is no joke.

    • Especially in the civilian world where most people don’t have the vaccination package that military people are required to have.

      As a civilian EMT, I’m not touching anyone’s blood. Period. The gloves I put on are to protect me, not them.

      Hep-B and Hep-C are no laughing matter, and they are some of the biggest threats to civilian EMT’s and paramedics. There is no vaccination (yet) for Hep-C. The Hep-B vaccination requires three shots over six months (the initial shot, another one a month later, and then a final shot at the six month mark), and costs big bucks, which is why most people aren’t vaccinated.

    • Gloves? You’re concerned about gloves?

      I’m curious who carries this kind of gear on them, all these quick clots, tourniquets, gauze rolls, splints and things. Wandering around at the mall, shopping, ice cream cone in one hand, young daughter clinging to the other.

      Seems like pretty bulky stuff to me.

      I can see it in a car kit, sure. But that’s not the situations being talked about here, you may not be able to get back to your car. Especially in the “you’re the one who’s wounded” scenarios.

      Seen a bunch of EDC load outs on various pages, none seem equipped like this, and frankly I don’t know where they would carry it if they did. It’s mostly gun, mag, knife, car keys, flashlight, phone and breath mints.

      But if you are equipped for this stuff, gloves shouldn’t be an issue.

      • I carry a single tourniquet, a bunch of tape, cor face shield, pressure dressing, gloves and a packet of quick clot with me whenever In the woods, shooting, hunting, or in another relatively high risk scenario, any other time it is in my car.

        Pick up a Boy Scout handbook or older first responder training book. Both detail how to do almost all of this(excluding chest seals-which I plan to add to my kit) with fairly common materials like tape,belts, shirts, sticks, etc. these are far from ideal, but can be effective in a pinch.

        The only thing I would emphasize is being in charge of the scene, use the people around you to dial 911, and gather supplies you don’t have on you.

      • I’m curious about this as well.

        From my personal experience, having something small enough that you will keep it *WITH* you, but big enough to be useful for treating more than a couple gunshot wounds is nearly impossible.

        Car kits are great – they can be virtually unlimited in size. But for something that needs to fit in the bottom of a knapsack or better yet in a pocket, it seems like you are limited to carrying just enough supplies to treat 1 seriously injured (shot) person.

        Anyone have a better idea? Please share..

  4. What To Do If Someone Else Is Shot: First, thank god or fate or luck or whatever that it wasn’t you.

  5. Two terrorists are walking through the dessert, when one of them grunts in pain and grabs his chest. His face turns blue and he keels over.
    The other terrorist radios HQ in a panic.
    “Help, Help, Achmed has had a heart attack, I think he’s dead. What do I do?”
    “Calm down Abdul. First, are you sure he’s dead? Make sure.”

    BLAM! BLAM!
    “Ok, he’s definitely dead, now what?”

    • There are much better things to pack a GSW with than a tampon, you’re not living in the 1970’s anymore. And even if you were in the 1970’s, a roll of gauze would be better.

  6. Thanks Doc. Good stuff, please post verbatim (absent improved information or the boss’ objection) every few months, as a nice refresher. That’s definitely worth still just ‘phoning it in.’ Seriously, thanks for the info Doc. I’d take a bullet for a Corpsman/Medic [or in ‘Obama speak’ Corpse-man] any day.

    Like the gouge on the Quick-Clot, we were told not to use on chest/abdomen wounds, no the packets have instructions, also know, if you need a clotting agent your hands are sticky, the bag is sticky, and the directions look like a Rorschach test.

  7. In the US civilian environment, triage is done to maximize the benefit of the limited medical transportation resources. In a MCI (multi-casualty incident), victims are categorized and tagged with the following colors:

    Green – walking wounded. They’re ambulatory, able to answer questions, respond to commands, etc.

    Yellow – Able to hold on for treatment or transport. Typically responsive, but perhaps disoriented.

    Red – Might be saved, but they need transport to a trauma center or hospital ASAP. Might not be conscious or responsive.

    Black – Dead, or going to be dead.

    The criteria for a black tag is pretty straightforward: no breathing or pulse? Black tag. Pulse but no breathing? If breathing cannot be rapidly re-established (5 rescue breaths or airway alignment/clearing), then they’re black tagged.

    Now comes the differentiation between red and yellow. Basically, a red-tag victim is someone who has a low BP, too low/high a pulse or breathing rate, severe penetrating trauma (of which a GSW is one), cranial injury, ejection from a vehicle, occupant of a vehicle with more than “X” distance of penetration into the passenger compartment, someone who fell from more than 20′ height, severe or widespread burns, etc. There’s a whole list of these criteria in EMT/paramedic practices. The biggest decisions are made between “red” patients (who need immediate transport) and “yellow” patients (who can hold on for awhile).

    The big difference between military and civilian triage is that in the US, ambulances or life flight aircraft can usually take only one patient per vehicle. Ergo, a MCI can quickly outstrip transportation capacity in many towns. In our town, a MCI with more than two casualties will require pulling in an on-call EMT crew who is perhaps up to eight minutes away from the ambulance station. Above three victims, and now our EMS system has to start calling EMT’s and paramedics in from off-duty to man ambulances.

    #1 thing people involved in a shooting must do in the civilian world is get a call into 911 and get EMT’s and/or paramedics en route. The longer this waits, the worse the outcome for the patients. In areas outside major urban areas, once EMT’s/paramedics/firemen arrive on scene, they might have to call the life flight service to fire up the choppers/airplanes to your area in order to get GSW victims to level 2 or level 1 trauma centers in a timely fashion. It is very difficult for a citizen calling 911 to get them to dispatch a life flight to your location without an EMT/paramedic looking things over and saying “get them coming.”

  8. Jon

    Where can I find you first post on TTAG?

    Where you discuss your combat medic and that you didn’t work on too many that were hit with 7.62 rounds.

    Thanks

  9. Bandanas and belts make great tourniquet, btw let EMS know who has a TK & why. If half the persons face isn’t there they are black tagged even if they still have sort of vitals. Don’t start CPR on the obvious dead or if your knowledge of performance is from T.V. offs are you will do nothing to help, take a class.
    Note if you are trained as an EMT etc… your state may require you to act and Good Samaritan act will not apply. Mass casualties will kick your adrenaline in taker a few breaths.

    I don’t know of many public places that will have more than a J&J 25 person 1st aid kit & maybe an AED with a baby size O2 tank. So darting a chest or starting a line is not likely unless you bring a jump kit everywhere you go. Plastic bags can be improvised for gloves.

    First priorities are to call 911 & make sure bad guy didn’t bring a friend & secure the BG’s hands shoelace will do. With his weapon away shove it out of reach DO NOT TOUCH IT. I

    Have walking wounded help, clear directions I.e. press here with bandage bleeds through stack another on top. Plastic wrap can be used instead of an Asherman seal. The hardest thing will be deciding if the 3 y/o who is going to die in a couple of minutes deserved treatment over the 70 y/o who has a good chance.

    You do the best you can & move on. A lot of the trauma courses that are advertised are great if you have a STOMP bag & they can be evacuated in 10-15 minutes. Find a course that covers improvised medical care also. BTW if you have nothing 10+ people yelling and aisle 5 has feminine hygiene products a sanitary napkin is better than nothing.

    As soon as all patients are turned over to EMS find a sink wash with soap and warm water, then hand sanitizer. If you can get a pulse, respiration allergies from any conscious patient write it on the chest, forearm, forehead may mean life death later. You likely are not going to see anyone besides a SWAT medic until PD says it’s clear.

    Yes I know everyone here has heard EMS was on scene & came in prior to it being cleared. That is an exception to the rule. Any of our local paid, private, or volunteers do that they likely will be fired or certification suspended. Most areas in SC have EMS separate in 2000 they combined ours with FD cost cutting. I have seen an ambulance, engine & ladder respond to a young female with a fractured elbow. Asked the Lt. why the large response “movie was over & it was a slow day”. Told me that it was called in as a multiple assault, bs since I called for a non-emergency. response had him listen to my recorder reply oops.

    If you start helping realize you.cannot stop until victims are turned over to EMS fire anyone with more training than you. If, more like when it comes to lawsuit your will be listed for abandoning patients. Ton of case law on it. 1 guy was a corpsman in Vietnam, did all he could but was removed by PD.family sued & won. It was reversed on appeal but he had to take his pension for legal fees.

  10. Just a point of clarification for both the medical and non-medical folks here; the expectant category, or black tagged, are not just to be left alone. Even if half their body is gone. They are simply your lowest priority patients. You still work on them when you have time, but only if you have time. Moreover, their category may change upon reassrsment. I have put a lot of patients in the expectant category, and some of them are alive today.

  11. I think life saving first aid equipment is a glaring omission in most peoples edc gear. There are way more accidental injuries, car accident deaths and the like then there are gsw in the u.s. i put gloves, a quicklot bandage, gauze, med tape, and a rubber tourniquet in my plastic food sealer, it compacted it to the size of a candy bar. It weighs 4ozs. I think the odds are in its favor to be more likely used to save a life than my ccw. Total cost is around $30 bucks, i think everyone should carry one, all the time.

    • Very much in agreement sir! a CAT tourniquet resides in my pocket, with plenty of kit in the bag in the car.

  12. Thank you for sharing the complexity that comes with a gun shot wound. So many times the movies embellish treatment of gun shot wounds, sometimes even leaving the person shot to handle it themselves. Of course, in a dire situation this would be appropriate, but the ease in which characters treat themselves with such serious wounds is misleading. It is so important to call medical personnel as quickly as possible if you or someone nearby has been shot. Being treated in a hospital is going to prevent further complications. Thank you so much for sharing!

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