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

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.

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.