Trauma Medicine for the CCW Operator

by Chris Upchurch, Suarez International Staff Instructor

The last weekend in October I took Suarez International’s Trauma Medicine for the CCW Operator. Medical knowledge is one of the biggest holes in people’s skill sets. Despite carrying and regularly practicing with firearms, preparing for the possibility that they may have to use a gun to defend themselves, many people never seriously consider that they or someone they love may be injured in the course of that gunfight. This class is for those who are willing to face that reality.

This class benefitted greatly from the exceedingly well qualified (if not overqualified) instructors. Dr. John Meade is Suarez International’s Director of Tactical Medicine, an emergency room physician and SWAT medic. He was ably assisted by Rick Klopp, a highly experienced S.I. Instructor and EMT. The third major instructor was a special operations medic who goes by the nom de guerre Sua Sponte. He’s got tons of experience patching up people with gunshot wounds overseas.

There were fourteen students in the class, including three Suarez International staff instructors (Alex Nieuwland, Scott Vaughn, and myself). We were also joined on the second day by C.R. Williams, who was shooting some video for promotional purposes. The other students were a varied lot. Some had a medical background, including several physicians and an EMT, while others came from a diverse array of backgrounds ranging from a farmer to a lawyer. I was particularly happy to see two of my former students in this class. I tend to harp on the need for some trauma care knowledge (see above for an example) and it’s nice to see that it seems to be having some effect.

This class was a bit different from most S.I. classes in that it was part of Warrior Skills Camp. This year WSC was a block of four classes held over a long weekend in Blairsville, GA. Rick Klopp taught a Force on Force class on Thursday and Friday. Alongside FoF and TMCO, Eric Pfleger, assisted by J.D. Lester, taught Rural Patrolling 1 and 2 in a big block running from Thursday to Sunday. The classes were held at Camp Jabez, a Christian camp north of Blairsville, with occasional excursions to a nearby range for the live fire portions. The camp provided food and bunkhouse style lodging. In addition to the classes, Rick organized a series of lectures in the evening from S.I. instructors and other volunteers. Having everyone staying in one place, taking their meals together really gives WSC a different feel than other S.I. courses.

This is actually my second experience taking a tactical medecine class at Camp Jabez. Two years ago I took S.I.’s previous medical class, Trauma Care for Shooters, from Karl Johnson at Camp Jabez. That was a really good class, so I came into this one with high expectations.

Friday Night

I traveled to Blairsville with Alex Nieuwland and another student from Columbia. The student was kind enough to volunteer his crew cab truck to carry us out there, since three people and all their gear (sleeping bags, clothes, force on force, and live fire gear) would have been far too much for the sedans that Alex and I drive. Even so, we managed to fill the bed of his truck and the half of the back seat that Alex wasn’t occupying pretty full.

Thankfully, everyone’s schedules allowed us to get an early afternoon start, so we could get there at a reasonable hour. The trip was fairly uneventful, though we had to stop and put some of the stuff in the back into plastic bags when it started sprinkling.

We got to Camp Jabez around 6:30. Most folks had finished eating already, but the kitchen had some food waiting for late arrivals. Walking into the dining hall was a bit like old home week for me. In addition to the various instructors (including Scott Vandiver, who was taking the Rural Patroling class) there were also quite a few folks who had either taken classes from me or been fellow students in classes I’d taken.

Once we were done eating there was an interesting lecture on OPSEC from Warriortalk member vlazlow. Afterwords Eric Pfleger and some other folks broke out the night vision devices. There was a range of generations (and costs) to play with and you could clearly see the difference in quality. My favorite was Eric’s PVS–7Bs (a Gen 3 single tube two-eye system). The quality was just amazing. Eric had an IR laser and flashlight on his rifle. That setup was pretty cool, definitely the way to go with a rifle. The goggles also worked well with the RMR on a TSD glock. The gun itself is too close to be in focus, it’s just a big blob, but the red dot shows up as a bright green point on your target. A set of these is definitely going on the to buy list. Eric has a way of getting me to spend unconscionable amounts of money.

Most folks headed off to bed (particularly those who Eric had been running ragged in Rural Patrolling). Eric, Alex, a student, and I hung out for about another hour, talking about hunting, shooting, and various other topics. Alex and I picked Eric’s brain about sniper rifles, since we’re both planning on going down to the Guerrilla Sniper class Scott Vandiver is teaching in Blakely, Georgia next March and I’m going to try to get out to Guerrilla Sniper 2 next fall.

Saturday Morning

After a nice breakfast on Saturday morning, we gathered and kicked things off. First up was the usual sort of admin stuff (fill out the liability waiver, promise on video not to sue anyone, etc.). With that out of the way John explained the goals of the class: to teach us to perform immediate first aid on gunshot wounds, as well as the gunhandling skills to stay in the fight even after being wounded. This class concentrates mostly on gunshot wounds, but the techniques cross over to other types of penetrating trauma.

To put things into context, John went through about some of the history of field medical treatment, explaining how civilian EMS grew out of and has been influenced by military battlefield medicine from WWII, to Korea, to Vietnam. The current framework for battlefield medicine is Tactical Combat Casualty Care (TCCC), which has it’s genesis in the Battle of Mogadishu in the early ’90s (a.k.a. Black Hawk Down). TCCC is divided into three phases: care under fire, tactical field care, and evacuation/definitive care. The key is that the right intervention is done at the right time. A medically correct intervention performed at the tactically wrong time is the wrong intervention. Treatment that might be appropriate during tactical field care or definitive care may not be appropriate while you’re still getting shot at. This class concentrates mostly on the care under fire phase.

The military defines the goals of TCCC as: complete the mission, treat the casualty, and prevent additional casualties. For most of us in civilian life, “the mission” is to keep ourselves and our loved ones from getting shot, so we can restate these as: don’t get shot, shoot back, and treat injuries. If you get shot in the head while treating a loved one’s gushing wound, that’s not going to do either of you any good. Finish the fight, then get people treated. “Victory is the best medicine”.

Once we get to a point where treating injuries is appropriate, our priorities can be defined by the acronym M.A.R.C.H.: Massive hemorrhage, Airway, Respiration, Circulation, and Hypothermia/Head injury. This is basically the order in which these things will kill you. This class concentrated mostly on the M, though we got into some airway and respiration stuff on Sunday.

With the basic framework laid down, John had everyone split up into three groups with different instructors. Sua Sponte taught about tourniquets, Rick Klopp talked about direct pressure, and Alex Nieuwland and I were tapped to go through the basics of Force on Force. After about 40 minutes, the groups would rotate so everyone had a chance to cover all the bases.

The FoF introduction was necessary because John opted not to have a prerequisite when he designed this course. It’s open to anyone who’s interested, even if they haven’t had any S.I. pistol or FoF training. This means we have to take some time to get everyone up to speed, but it also means that we can get this critical lifesaving medical knowledge into the hands of as many people as possible.

Given the need to come up with an impromptu 40 minute Force on Force boot camp, Alex and I were really glad we’d just done Randy Harris’ FoF class two weeks earlier. We basically lifted a very compressed version of his curriculum. First, the students drew and shot each other from a stationary position. Unless someone completely flubbed their draw (which happened a few times) they got shot. We went through the basics of getting off the X and had students move out of the line of fire. One student played the bad guy and drew and shot at the position where the other student was standing. The other student played the good guy and his job was to get out of the way. Everyone was able to get off the line of force before the BG fired. Next up we introduced drawing as you move off the X so you’ve got a chance to shoot back at the adversary. After we’d run this in a couple of variations, it was time to rotate. I think by the time the third group came around Alex and I were pretty good at teaching this.

One of the nice things about it being a fairly cool morning was that it was actually relatively comfortable to wear a thick sweatshirt or a couple of layers of clothing so that the airsoft BBs didn’t hurt so much (unless you got hit in the hands, as you often do). The downside to this is that the cool air makes the airsoft guns, which rely on pressurized gas, less effective (curse you laws of physics!). Some of the issues we saw reinforce my belief that if you want to get the most out of a FoF class, you should really bring two airsoft guns, because that’s what it takes to keep one running most of the time.

After each group had rotated through all three blocks of instruction, we reconvened in the classroom. John and Sua Sponte went through some of the available gear, particularly tourniquets. John is quite emphatic that the SWAT and TK–4 tourniquets are basically useless. It’s difficult or impossible to get them tight enough to cut off blood flow to an extremity. The three tourniquets that he recommends are the Cav Arms tourniquet, the CAT, and the SOFT-T. Each has their advantages and disadvantages in terms of size, weight, bulk, cost, and complexity, but they all work After taking Karl’s class two years ago, I’d bought several CATs, but I am intrigued by the Cav Arms TQ. It’s actually small and light enough I could see sticking it in a cargo pocket and carrying it on a daily basis, something I’ve never done with the CAT.

Sua Sponte went through various hemostatic agents. He took some of the old first generation Quick Clot and added it to a water bottle to demonstrate how much heat it produces when activated. It actually partially melted the bottle. His current favorite is the ChitoGauze and Celox Gauze, both of which are gauzes impregnated with a hemostatic agent. If you’re applying direct pressure to a wound you need gauze anyway, and the gauze makes it easier to get the hemostatic material where you need it.

Saturday Afternoon

After lunch we reconvened and split into two groups. These groups rotated back and forth between John and Rick and Sua Sponte working together. Both sets of instructors had us practicing some integrated force on force and medical scenarios. Dividing up and rotating helped lessen the load on the instructor and gave the students a chance to see some different takes on the same material.

My group went with Rick and Sua Sponte first. We started out fairly simple, with one on one FoF gunfights and each participant administering a tourniquet to an injured limb after the initial exchange of airsoft BBs. After a few rounds of this, we started incorporating some twists, like two good guys withe one providing aid to the other, or moving to cover.

After about an hour of this, we switched over to John. He had us doing much the same thing, but with some twists. He really emphasized the after action assessment. We teach after action drills, which include a self-check to see if we’ve been injured, but generally don’t talk about what to do if it comes up positive. One thing John introduced that I hadn’t really seen before was the idea of squatting during your after action drill to perform a physical check of your lower extremities. This allows you to keep your head up rather than spending a lot of time looking down at your feet.

Switching back to Rick and Sua Sponte we practiced patient movement, dragging a weighted dummy to cover and treating it. Back to John again and we worked some with an improvised tourniquet made from a bandana or cravat, a keyring, and a climbing carabiner. While this isn’t nearly as quick as a premade TQ, it’s something you can make from materials at had, particularly if you have a handkerchief and clip your keyring to your belt with a carabiner (the carabiner also has lots of other uses).

We came back together in the classroom and went through some of the lessons learned from the FoF exercises. One that comes up in FoF a lot, but has special resonance in a medical class, was the prevalence of hand and arm hits. People tend to focus on the gun, resulting in them shooting at it. Even if they’re focusing on the chest rather than the gun, the gun arm is often still in the line of fire.

The frequency of hand and arm hits brings up several issues. Can you shoot ambidextrously? Do you have a gun accessible to both hands? Similarly, can you apply a tourniquet with either hand? Is the TQ accessible to either hand? During the scenarios some folks were gaming the tourniquet positions, putting it where it would be most advantageous before each drill. Moving your TQ around is a recipe for disaster, since it will leave you patting yourself down looking for it when you need it. Just like with your gun, always carry it in the same place. Moreover, if you’re part of a team, the team should have an assigned spot for their individual first-aid kit (IFAK), so that a rescuer will know exactly where to find this stuff.

Sua Sponte talked about the priority of items in a trauma kit. If you can only carry one piece of trauma care gear, he recommended a tourniquet. Interestingly, he gave duct tape second place, largely for it’s multipurpose nature (and yes, you can tape wounds shut if necessary). John emphasized the need to keep your booboo kit (band aids, aspirin, Sudafed, etc.) separate from your trauma kit. The trauma kit should be very focused, don’t dilute it or give yourself the temptation to draw down trauma supplies by mixing the two. Finally, they emphasized that the tourniquet (being the most important item in the kit) should be on top or most easily accessible.

Saturday Evening

After dinner we had a very interesting series of lectures from Rick Klopp, John Meade and Eric Pfleger. Rick talked about land navigation and in particular using a military protractor (a plastic square with markings for measuring coordinates, distances, and bearings on maps) and a topographic map to measure coordinates and azimuths.

John had an interesting lecture about bites with lots of graphic pictures. He covered spider bites, scorpion stings, and snake bites. As a wrap up he had a picture of a particularly nasty shark bite. The fellow was missing his hand and all the flesh in the lower half of his forearm was removed, leaving just the radius and ulna bones sticking up.

Eric wrapped things up with a lecture on mantracking and counter-tracking. I’d heard some of this stuff at the Guerrilla Sniper class, but this was a bit more detailed. I’m certainly not knowledgable enough to track anyone (or evade a tracker) just based on one lecture, but now I know a bit about the issues involved.

After the lectures Eric brought out his NVGs again. Unlike Friday night, tonight was clear, so we could use them to look at the stars. Thanks to the light intensification you can see a lot more stars than you can with the naked eye. About like looking through a good telescope, but with a wider field of view. To quote Dave Bowman in 2001, “My god, it’s full of stars!”

Sunday Morning

Sunday morning we started off with a bit more discussion of tourniquets, in response to some student questions.

John gave a lecture on the role (or rather, the lack therof) of CPR in trauma care. This is a subject he really seems to have a bee in his bonnet about. CPR was intended for people who had garden variety heart attacks, to keep the blood pumping until some other intervention could be applied. It was a way of buying time. The problem is if you’ve got a leak in the system, all pumping the heart does is pump more blood out. The focus needs to be on keeping as much blood as possible inside their system. There are some situations other than heart attacks where CPR is appropriate, like electrocution, hypothermia (after warming), and near drowning. However, none of these involve massive blood loss. The bottom line is if someone’s heart has stopped beating due to blood loss, they’re dead. Anything after that is molesting a corpse.

John also noted that many agencies and training classes rigidly mandate against moving anyone with a “trauma injury” unless they’ve had a cervical collar attached and they’ve been tied down to a backboard. That may be appropriate for somebody who’s been in a car crash, but for gunshot wounds it often makes no sense. That round through their leg did not magically cause a neck injury. Don’t be afraid to move someone (particularly to move them out of the line of fire or to cover) just because you heard somewhere that you shouldn’t move anyone with trauma injuries.

Once again we split up into two groups. One went with Rick Klopp and talked about splinting while Sua Sponte covered airway management.

Rick talked about the purpose of splinting broken bones, and emphasized the importance of not making someone’s injuries worse. You should check the limb’s nerve connections before and after splinting (ask them if they can wiggle their fingers or toes and feel you touching them), as well as the limb’s blood flow (check the capillary refill time by squeezing their finger at the nail and seeing how long it takes for the color to return to pink).

For the practical application, Rick had several Sam Splints (basically a thin layer of aluminum between sheets of foam). They can be bent and molded into whatever shape you need to support a limb. I’ve got one of these in my backpacking first aid kit. He also talked about improvised splints, and towards the woodpile for materials. We practiced splinting various injuries on arms and legs, and talked a bit about immobilizing back injuries.

We rotated over to Sua Sponte to talk about airway management. The primary problem here is that if someone looses muscle tone their tongue can fall backwards and block the passage of air. The basic way of remedying this is the “head tilt chin lift”, basically tilt their head back and open their mouth. The problem is that if you don’t keep holding their head in position, it may slip and they’ll loose their airway. Sitting there holding their head may not be a problem if all you’re doing is waiting for the ambulance to arrive, but if there’s still a fight on or more than one casualty you need to treat.

A solution to this conundrum is the nasopharyngeal airway or NPA. An NPA is basically a rubber tube that goes in through the nose to the top of the throat. It ensures that the tongue doesn’t block the airway and allows you to move on to other matters rather than keeping the patient’s head in position. Sua Sponte showed us how to insert one on a dummy head, then gave us the chance to practice on it.

NPAs are one of the things you often see in pre-packaged trauma kits, but I’d avoided adding one to mine since I didn’t feel like I know what to do with it. Now that I’ve gotten some professional instruction and some practice, I think I’ll probably be adding one to my kits.

While the NPA will protect the airway from the tongue, the patient can still end up drowning in their own blood or vomit. We can lessen the chances of this by repositioning the patient onto their side so that any fluids will drain out of their mouth. Sua Sponte showed us how to do this. It’s basically the same way you roll a drunk over to keep them from choking, but given the fact that our patient probably has some other injuries there are some special considerations about which side to roll them towards and how to stabilize them.

Next up we did some dry fire, working on one-handed gun manipulation. Half the group worked with John, Rick, and Alex and the other half came with Sua Sponte, CR Williams and I. As we saw in Force on Force, hits to the hand and arm are quite common. Thus far we’ve concentrated on tourniqueting an injured limb, but before we get to that point we have to finish the fight first.

We started with transferring the gun from one hand to another. The technique for doing this with a wounded arm is a bit different than our regular hand to hand transfers, since you can’t expect the hand you’re transferring from to do as much. It’s more like picking your gun up off the injured hand than passing the gun from one hand to another.

Next we worked some one-handed reloading and malfunction clearance drills. These involve putting the gun somewhere (either kneeling down and tucking it behind the knee or putting it back into the holster) swapping mags, and racking the pistol using the rear sight on any handy surface. After doing this with just the dominant hand we did the same thing just using the support hand.

While hand and arm hits were the most common, leg hits happen too (particularly against someone who has a bad trigger jerking problem). A leg hit may put you on the ground, as could being physically bowled over in a confrontation. Accordingly, we worked on some shooting from supine (lying down on your back) and prone.

Sunday Afternoon

After lunch we convoyed over to the range for the live fire portion of the class. We started out with some dry draws from the holster, then moved on to drawing and firing single, precise shots. These drills served mainly to make sure everyone was up to speed and could draw and fire safely, since the class has no prerequisites. Everybody seemed to have a fairly decent drawstroke, so we moved on to shooting in bursts.

Next we incorporated the after action assessment. Again, we did this dry first to make sure everyone had Sul down pat, then went live. Of course, the next logical step was to add discovering an injury during the after action assessment and apply a tourniquet. We ran through applying tourniquets in various places and making sure everyone got to use the different types of tourniquets.

The next batch of drills got quite a bit more dynamic. They incorporated shooting on the move, then moving to assist an injured friend (played by a dummy). Because these involved a lot of movement, John ran these two people at a time, on opposite sides of the range so they wouldn’t interfere with each other. This was the day before Halloween, so he broke out some zombie targets for us to shoot at. I saw quite a few body shots though; some people evidently missed the memo that you’re supposed to shoot zombies in the head!

Once everyone had rotated through the drill, we began repeating it with twists thrown in. You might have to reengage the threat when he pops back up (again, zombies need to be shot in the head), move the injured person to a safer location, deal with more than one injury, or multiple casualties, etc. This is where the whole class really comes together. You’re not just applying a tourniquet, you’re also moving, fighting, and making tactical and medical decisions. This wrapped up the shooting portion of the class.

Before handing out the certificates, John talked a bit about the more advanced medical classes S.I. is going to be offering. The second level class, Advanced Trauma Medicine will be offered for the first time next April in Orange, Texas. The third level class, Trauma Combat Casualty Medicine isn’t even on the schedule yet, but I’m sure it will be once ATM has been taught a couple of times. He went over the curriculum for these classes and they’re going to incorporate some pretty advanced stuff. I am really looking forward to the opportunity to take these classes.

With that, John passed out the certificates and we wrapped things up.

Final Thoughts

This class was truly outstanding. Even having taken a tactical trauma class before I learned a lot. Someone coming in with Red Cross or Boy Scout level first aid skills would certainly learn a tremendous amount. The medical knowledge conveyed was great, but what was truly outstanding was the way John has integrated the medical and fighting skills. This isn’t a class where you learn a bunch of medical stuff, then apply that to a fighting context at the end, the fight is integrated into the class from the very beginning. We started doing force on force less than an hour after the start of the class and were consistently doing either FoF, dry practice, or live fire all the way through.

In addition to the curriculum, a lot of credit has to go to the instructors. John did an excellent job teaching this class. He’s clearly got an enormous depth of medical knowledge in the area and he’s quite able to explain these issues in plain language. Rick Klopp did a great job as co-instructor. I’m sure he could have taught this class himself (and he will in Atlanta next May). Finally, I really have to give some special thanks to Sua Sponte. He’s got vast practical experience in these areas and it shows. As with John, he’s also got the teaching skills to convey his knowledge to others. His presence really elevated the class. While he’s great at the medical stuff, I would love to get into a class where he was teaching his other military specialty: sniping.

In addition to Rick’s great work as an instructor in this course, he also organized Warrior Skills Camp. While every S.I. class I’ve taken has been a good experience in terms of fellowship with the other students and instructors, WSC has a unique vibe. Having everyone bunking and eating in the same place provides a really great experience. Camp Jabez is an excellent facility for this sort of thing and they did a great job feeding us. I also need to thank vlazlow, John, Rick, and Eric for their lectures during the evenings. They were an informative bonus on top of all the class material. Hopefully Rick will organize Warrior Skills Camp 2012 next year. I would highly recommend the experience.

Taking this class has caused some changes in my own thinking, particularly about medical gear. After learning about the Cav Arms tourniquet and talking with Sua Sponte about some low-profile options for pressure dressings, I think I’m going to start carrying them on my person on a regular basis. I generally wear cargo pants but I hardly ever use the thigh pockets for anything, so I might as well carry some trauma gear in there. I’m also going to add some hemostatic gauze and a nasopharyngeal airway to the trauma kits in my range bag and bug-out bag. Now that I’ve been able to practice with the NPA I feel confident enough to include one in my kit. I think I’m going to upgrade my little wimpy keyring carabiner to a real climbing one. It’s just too useful, both for improvised tourniquets and other stuff.

The skills taught in Trauma Medicine for the CCW Operator are really vital for anyone who carries a gun or plans to defend themselves with a firearm. I think John made with right choice in not putting a prerequisite on this class, making it available to as many people as possible. However, as Alex suggested during the drive home, even though there’s no prerequisite in the course description, this class really has a mental prerequisite. Most CCW carriers would probably be mystified, if not horrified, by the stuff we’re learning in this class. They just haven’t even considered, or don’t want to consider, the possibility that they or a loved one might be injured in a gunfight. Getting to the point where you take a class like this is a mark of maturity and realism.

This was an excellent class, with excellent instructors. The medical skills are vital lifesaving knowledge for anyone who spends a lot of time around firearm and they’re integrated into the context of a fight from the very beginning of the class. I would highly recommend Trauma Medicine for the CCW Operator, as well as anything taught by John Meade or Rick Klopp.

Images courtesy of Dr. John Meade and Alex Nieuwland