by Chris Upchurch, Suarez International Staff Instructor
Last weekend I came up to Winchester to help Dr. John Meade and Jack Rumbagh with the Trauma Care for the CCW Operator class. I took this class last October in Blairsville at Warrior Skills Camp, and I helped with the class in Crestview a few weeks ago. Since this was such a large class John invited me to come up and help. The reason I came (besides helping a brother out) is that this is exceedingly important lifesaving knowledge and learn something every time I come to one of these.
As mentioned earlier, this class was rather large, with 22 students. Many of them werre S.I. training junkies, who had trained with Jack before (often quite a few times). The class also included a group of Navy Corpsman from Marine Barracks, Washington D.C. (also known as 8th and I). In addition to the Corpsman, several students had medical experience, including a couple of nurses and at least one doctor.
I’d been warned it was quite a long drive from Winchester out to the range Jack teaches at and John likes to start the festivities at 8 o’clock, so I left the hotel good and early. The day dawned overcast and shortly after I got there it started up with a sprinkling. The rain would continue throughout the day, alternating between a light drizzle and some fairly heavy rain. Despite rain gear, everyone was pretty damp by the end of the day.
We started promptly at 8 with the usual administrative business: passing out waivers and promising on video not to sue. With that out of the way John began his introductory lecture.
Fundamentally, this is a class that integrates tactics and medecine. Students would begin the class alternating between force on force drills and medical lecutre, and soon start integrating their medical knowledge with force on force, dry fire, and finally with live fire.
John talked about the history of tactical medecine, from the Civil War up until the present day. In particular, he discussed how developments in battlefield medecine (such as ambulances, field medics, hellicopter transport) have influenced the development of civilian EMS. A key point in this developmet came with the Battle of Mogadishu (the basis for the book and movie Black Hawk Down). After the battle, the Army created a committee to analyze what lessons could be learned medically. This led to the concept of Tactical Combat Casualty Care (TCCC or tee-triple-cee). The fundamental idea behind TCCC is that the right intervention delivered at the wrong time is the wrong intervention. Treatment not only needs to be medically appropriate, but also tactically appropriate as well. TCCC divides treatment into the care under fire, tactical field care, and evacuation/definitive care phases. This class focuses mostly on the care under fire and tactical field care phases (with a bias towards the former).
Most first aid classes (particuarly those oriented towards CPR) use the menomnic A.B.C (for Airway, Breathing, Circulation). For penetrating trauma, this is the wrong order. Massive hemorrhage will kill much faster than a breathing problem (within 2 mintues for a severed femoral artery). For this sort of situation John prefers the acronym M.A.R.C.H., for Massive hemorrhage, Airway, Respiration, Circulation, and Hypothermia/Head injury.
We split the class into three groups. Two of these did a quick introduction to Force on Force with Jack and I, while the third learned about tourniquets from John. This is the third time I’ve been called on to teach the force on force component of TMCO, so I’ve got down fairly well. We started with the basic get off the X fundamentals, then moved on to some basic scenarios, including multiple good guys and bad guys. Thankfully, unlike the Crestview class, there were plenty of students to serve as opponents for each other in FoF, so I could let them beat up on each other, rather than getting pelted with little plastic pellets myself.
After lunch, John resumed the lecture, telling students about some tourniquets he doesn’t recommend: the TK–4 (and it’s predecessor the TK–3) and the SWAT-T. The problem with both of these is that they don’t really work. It’s almost impossible to get them tight enough to truly cut off blood flow to the injured extremity. John also showed off a ratcheting tourniquet that uses a mechanism very similar to the tie-down straps you can get at the hardware or automotive supply store (in fact, he recommends you just get one from the hardware store and cut it to length rather than paying five times as much for the one from the medical supply store).
He also talked about improvised tourniquets. WhenJohn asked students what they’d use to improvise a tourniquet the nigh universal reply was ‘a belt’. However, when asked to do so, nobody was able to get a belt tight enough to cut off circulation. Belts, particularly gun belts, are far too stiff to make a good tourniquet. There’s no way to tighten them down enough to cut off blood flow. Far better is something thinner and more flexible. John demonstrated using a triangular bandage, but almost any piece of cloth will do: a t-shirt, pant leg, scarf, etc. As long as you can tie it around the limb and insert a windlass and twist. John’s favorite windlass is a carabiner. He uses one to carry his keys (and convinced me to do the same). That way, just with what you’re wearing you can improvise a tourniquet if necessary (one that will actually work!).
With the lecture out of the way we stepped back out into the rain for more Force on Force. We taught the students the standard S.I. after action assessment, which includes a medical self check. In most classes we include the self-check, but generally assume that we came out of the gunfight fine. In this class, we assume the opposite: that there’s a problem that needs to be fixed with a tourniquet.
This time we integrated tourniquets into force on force scenarios, having the students apply a TQ to the limb they were hit in (or specifying a limb if they weren’t). We started off with simple one on one scenarios, gradually increasing the complexity by adding in additional good guys, cover, and other complications. Since we had three instructors on hand, the students rotated among John, Jack, and I.
We got back together and talked about some of the lessons learned. As usual with FoF, nobody spent a lot of time with a perfect sight picture. Lots of hits to the hands and arms. As Roger Phillips puts it, “the bullets go where the eyes go,” and people tend to look at the gun. This has some implications for one-handed and support hand shooting and gunhandling (something we’ll get into tomorrow), as well as being able to apply tourniquets one-handed. This led into a discussion of where to carry your tourniquet. You want to be able to access it with both hands, and from a variety of positions, including lying on the ground. In front near the centerline is best, and if you’re operating in a team environment, the position should be standardized.
John finished out the day with a discussion of the mindset necessary to deal with violence and with the medical issues like the ones we were training for in this class. With that we wrapped things up.
John, Jack, and I, along with several of the students, adjourned to a local watering hole (the Piccadilly Pub) for some excellent food and even better conversation. We stuck around until after 8 o’clock eating and talking. Fellowship with like minded folks is always one of the best parts of a class like this.
Sunday morning dawned overcast again, but overall the weather was better than the day before. We only got a few light sprinkles, which was a welcome relief from the previous day’s rain.
We started off with some discussion of some first aid techniques that are inapplicable to penetrating trauma such as a gunshot wound. It’s gotten to the point that, if someone doesn’t have a pulse, the default response is CPR. This works well when their lack of a pulse is due a heart attack, electrocution, or drowning. When their heart has stopped because they’ve lost too much blood, it’s a different story. By performing CPR you’re just squeezing more blood out of the holes that caused the problem in the first place. What’s more, you’re tying yourself to a single location and performing a task that takes your attention almost completely away from the tactical situation. This just isn’t the right context for CPR.
In most first aid classes you’re taught not to try to move anyone with a traumatic injury, lest you exacerbate a (potentially hidden) spinal injury and paralyze them. If someone has just fallen off a roof or been in an auto accident, this is a legitimate consideration. If their trauma is a gunshot wound to the leg, however, it’s not going to magically affect their spine. Don’t be afraid to move gunshot wound victims to a better position, behind cover, etc. just because they have ‘trauma’.
With these out of the way, we split up into two groups. John drafted the Navy Corpsmen’s Chief Petty Officer (Housertl on Warriortalk) to talk about airway issues while John, Jack, and I covered splinting and patient movement. If you want to read about the airway stuff, take a look at the writeup from the TMCO class in Blairsville.
John started by talking about which injuries can benefit from a splint. You generally hear about splinting broken limbs or bad sprains, but splints are much more widely applicable than that. Splinting can also help with dislocations, muscle or tendon injuries, even bad bruises. Basically if it hurts when you move it, immobilizing it might be a good idea (“Doctor, it hurts when I do this!” “Then stop doing that.”).
He brought out the SAM splints and talked about how to use them. They’re basically a flexible sheet of aluminum sandwiched between two pieces of foam. You can mold them to any shape desired and when you put a bit of a curve into them they become quite strong. Because of their size they’re probably not an EDC item, but given their low cost and light weight it’s easy there’s no reason not to throw a couple into a larger medical kit.
Nevertheless, if a premade splint isn’t available there are lots of options. John talked about the requirements for a good splint (stiff, right length, not too heavy) and various methods for attaching them. There are many (tie using bandages, repurpose a tourniquet, etc.) but John favors duct tape. He sent the students off to collect improvised splints and had them splint up the dummy.
After removing the splints from the dummy, John talked about patient movement. Moving dead weight is a lot harder than it looks. People weigh quite a bit, and their lack of good handholds and tendency to flop around makes them harder to deal with than other objects of similar weight. This is something a lot of TV shows get wrong, and John mentioned watching a character on crime drama easily heave a dead body into a dumpster and contrasting it with how hard it was to get the dummy we were using out of the car.
John had everyone try to move the dummy a few feet. Lots of folks were surprised by how difficult this was. The dummy weighs about 165 pounds and, like the human body, it tends to flop about. Most folks tried just scooping up the dummy from under the armpits, which works, but not very well. John showed a technique where you can reach under a person’s armpits from behind and grab the opposite wrist in each hand. This provides a better hold and keeps the arms from flopping about. It’s still difficult and you’re probably not going to be hauling folks the length of a football field, but if they’re a few yards from cover, this can work.
After lunch, we split up again, with half the group going with John for some more tourniquet work and the other half coming with Jack and I for some weapon manipulation. As mentioned earlier, one of the most common places to get hit is the hands and arms. Given this, you need to be able to manipulate your pistol one-handed. We talked folks though the one-handed reload, as well as methods for getting the gun from one hand to the other.
Some folks were somewhat impeded by their equipment. If you’ve got very slick, low-profile sights like Novaks, they can make it difficult to rack the slide by hooking the rear sight on something. This is why I prefer rear sights with a fairly vertical front face, like the Warren Tactical or Heine Ledge models. Of course, if you’ve got a TSD gun with an RMR on it, the optic works just fine as a charging handle.
Finally, we moved over to the range for the live fire portion of the program. As usual we started with very simple draw and shoot drills, then proceeded to integrate the after action assessment and tourniquet use.
We split the class up into three groups. Two lined up on each side of the range to shoot some more dynamic drills while I took the Corpsmen and did a quick, lesson on how S.I. thinks folks should run the M9. This is a bit different that what the military may teach, but we think it’s considerably more effective in a fight. Basically, we run them like a Sig. Never leave them with the safety in the on position. Before holstering pull it down to decock then push it back up to the firing position. If a Glock with a 5.5 pound trigger is safe to holster without a manual safety, the Berretta, with a double action trigger pull of at least twice that does not need a manual safety.
With the pistol instruction out of the way, we did some work getting up off the ground while keeping the pistol on target. Unfortunately, we could not do this live because we had a very low berm in the area we were using, but doing it dry gets the basic concept across. After everyone rotated through getting up off the ground and the more dynamic drills John and Jack were running, we wrapped things up. John handed out the certificates and we all packed up and headed home.
As usual from John, this was a great class. This has been my third time seeing it taught and John continues to deliver a very high quality, well organized experience. The integration of the force on force and live fire with the medical stuff does a great job putting this into context and reinforcing the fundamental principles of TCCC.
We had a really great group of students in this class. Many had trained with Jack several times before, and it showed in the FoF and on the range. Despite having a large class we were able to get through things quickly and smoothly thanks to the very well squared away students. It was also nice to be able to put a face to quite a few folks that I’ve only met online on WarriorTalk.
This is truly an excellent class full of vital lifesaving information. Everyone who carries a gun for self defense, or even who just spends a lot of time on a gun range, needs this knowledge. We’ve got a bunch of these on the schedule all around the country. Sign up now! You won’t regret it!
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