Read the first of this two post series here.
Being shot and having to treat yourself isn’t 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’ve been shot, if someone else is shot, your first order of business should be ending the threat. If the threat is ongoing, that means returning fire.
As I 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. That’s the time you have 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’s only one person shot, get right on that. But what if there is more than one? Whether 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 help you master, but there are a few techniques that will help.
The overriding rule of triage: 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. You will be able to make those decisions as well, and people will be better off for it when you do.
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 in order to work on a conscious adult. I did that more than once because I had a better chance of saving the 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. If you don’t, it’s possible that both the adult and the child will die.
Note that 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 probably die. And they would die because I would have to ignore them to save the one who I thought I could do something about.
Just understand that those decisions will have to be made — very quickly and correctly — or everybody suffers and more will die. The worst possible thing is to wait. Waiting is tantamount to murder.
Also, once the threat is gone, everyone who is wounded is a patient. Everyone. That includes the aggressor. Yup, you have to treat the shooter. This isn’t a philosophical debate. If they’re no longer a threat and they are wounded, they are a patient and you have to treat them to the best of your ability. That means triaging them appropriately, too.
I have treated the enemy before myself. Try and avoid that scenario if possible.
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 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, “Okay, 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. You are only treating them for life, limb, and eyesight. You treat everyone you have time to treat and none who 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’s the victim.
Getting the GSW victim to call 911 is a very good thing. It keeps them engaged and conscious while freeing you to work. If there’s no one else who is conscious, but you have more than one victim, call 911 now. The same rules for putting the phone on speaker phone mode apply. 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’s a more competent medical provider there, you are in charge of helping the victims.
The first thing you’re 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’s 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’s 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, don’t 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 okay 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. The general rule for you, if you aren’t 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 didn’t need one at all and now they need a thoracotomy. That’s not ideal. Skip it unless you really know what you’re 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. Don’t put a pillow under a GSW patient’s head unless there’s 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’re 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’s no need to perform CPR if you cannot control bleeding, or if there is another patient you can help. You will perform CPR unless and until 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 it’s time to splint up injuries, bandage eyes, get patients out of the cold or extreme heat, and get them ready for the ambulance or other transportation. Unless you are way out in the woods, there’s 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. Check and see if it’s 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’re 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’d 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 Ziplock 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.
Read the first of this two post series here.