Medical

It’s Hot, Dammit

A local man was part of a landscaping crew, and wasn’t feeling well because he had used a little meth that morning. His coworkers told him to go take a break in the truck with the air conditioner running. He crawled in and passed out without starting the truck. That day, the heat index was 105 degF. Inside of that uncooled truck, it was much higher. An hour later, they went to check on him and found him unresponsive and covered in vomit, so they called 911. The ambulance crew rushed him to the ED, and he went into cardiac arrest during the trip to the hospital.

When he arrived at the hospital, his rectal temperature was 110 degrees F (43.3 C). We worked him for an hour and a half. I was in charge of getting fluids into him. I pressure infused 6 liters of refrigerated Normal Saline into him. He was covered in cold blankets and had a fan blowing on him. We finally got his rectal temp down to 100degF, and got pulses back. He wasn’t even 30 years old, and wound up dying later that day of the heat stroke that literally cooked his brain.

I saw Graybeard’s post about the hot days of summer, and I will second that. The people who live here know that anything needing to be done outside is best done before 11 am, when the thermometer typically breaks 90 deg. It isn’t the temperature, it’s the dew point. As of right now, the dew point here in Sector Ocho is 73 degF. Yeah, we do this every year. Here we are complaining about humidity from back in 2016.

The dew point temperature is the temperature at which the air can no longer hold all of its water vapor, and some of the water vapor must condense into liquid water. At 100% relative humidity, the dew point temperature and the air temperature are the same, and clouds or fog can begin to form. Dew point is the best indicator of comfort in a hot climate. Once the dew point of the air exceeds 66 degrees Fahrenheit or so, the air begins to feel hot and uncomfortably stuffy. The reason for this, is that your perspiration can not evaporate to cool you off.

The thermometer temperature and the dew point are used to calculate the heat index (feels like) temperature. Any heat index above 125 degrees is likely to produce heat stroke, which is deadly.

Here in Florida, there are 4 seasons:

Hot: March through May
F’ing Hot: June through mid September
Still Hot: Mid September through Mid November
Snow Bird: Mid November through February

When it’s hot, you get your outside work done in the morning, then stay in the air conditioning until at least 4:30 in the afternoon, when the afternoon thunderstorms come calling. That is what we do from mid June until about the middle of September.

By Divemedic, ago

Be Positive

Miguel points out that many people don’t know their blood type. He says you should find out. It will help you avoid what happened to my friend when he got shot. He needed blood, but we didn’t know his blood type. He kept telling us to be positive, but it’s really hard to do while your friend is dying.

Get yourself a blood tag like one of these, and affix it to your kit, or to your usual range attire. It will save some time when time is critical. (And no, my blood type isn’t B+)

By Divemedic, ago

Posturing

The nice folks over at GunFreeZone posted a link to a video and expressed an opinion on posturing. I invite you to go and check it out. Unfortunately, that opinion is incorrect. JKB makes the claim that the loser of the fight is displaying decorticate posturing. He is wrong.

What you see in the video is decerebrate posturing. In the difference lies a huge change in prognosis. All posturing is a common outcome of severe brain injury. It refers to involuntary and abnormal positioning, and the presence of posturing after TBI suggests a poor prognosis.

Both types of posturing often indicate some extent of damage to the brainstem, which is the part of the brain that controls important functions like breathing. Decerebrate posturing, which is what we see in the video JKB linked to, is caused by damage to deeper brain structures and is much more common than the other type, decorticate posturing. Decorticate posturing is caused by damage to both hemispheres of the cerebral cortex and is rarer than decerebrate posturing, but is generally associated with better survival rates.

Generally, the recovery outlook for individuals with abnormal posturing after brain injury is poor. Even though there are instances where individuals regain consciousness and recover, only 37% of those who display decorticate posturing after a head injury survive. Only about 10% of individuals with decerebrate posturing survive.

In the video JKB links to, the individual displaying this posturing has one thing going for him: Youth. If he is admitted into the hospital within 6 hours of his injury, he is likely to double his chances of survival, even though it is still likely that he will have some permanent disability. So an 80% chance of death, and a 20% chance of permanent disability. All of that from a punch to the head.

Think about that the next time someone says that a concealed carrier should just take “his beating like a man.”

By Divemedic, ago

Airplane Medical Kit

Because of the comments to the post about the doctor on the airplane, I wanted to do a follow up. So let’s first talk about what is in the medical kit on a commercial aircraft. The FAA requires an AED, and a medical kit that contains the following items:

The most common inflight medical events are:

  • Gastrointestinal/Nausea (31%)
  • Neurological, such as fainting or seizures (26%)
  • Respiratory (7%)
  • Cardiovascular (5%)
  • Dermatological (5%)

My wife was on an aircraft flying from JFK to Heathrow where there was a death in flight. The flight attendants cleared out the back row of the plane and put the body on the seats, covering him with a blanket. That is where he stayed for the remainder of the flight.

I myself have been on two flights were there were medical issues. In both cases, the flight crew called for medical personnel. I wasn’t going to volunteer, but no one else did, so I raised my hand. The FA brought me a radio headset that was connected to the airline’s on call doctor, who consulted with me and we agreed upon a course of action.

The first was a moderate allergic reaction (urticaria, wheezes, pruritus) on a flight from Orlando to Boston. The passenger got himself 50mg of IV diphenhydramine and some inhaled albuterol. He was fine and slept the rest of the flight.

The second was on a flight from Las Vegas to Orlando. It was a guy who was having himself an anxiety attack. He was hyperventilating and complaining of shortness of breath, chest pain, along with numbness and tingling to his fingers and lips.

The reason for it was hilarious. He had gotten married to his fiancé (a white woman) while in Vegas. He was Puerto Rican, and was dreading his mother’s reaction when he told her that he had married a woman (who wasn’t Puerto Rican) that his mother hadn’t even met yet. If you know anything about Puerto Rican mothers, you would know that they are much like Italian mothers. He had every right to be afraid.

Anyway, I told the doctor that his vitals looked good and I felt like it was an anxiety attack. The doctor agreed. I traded seats with his wife for about half an hour and talked him down. Once he felt better, I went back to my seat. An hour later, his wife came and got me a second time. During that second visit, his wife told mine that I was a very patient and nice man.

That’s it for my aircraft stories.

By Divemedic, ago

Childhood Development

When a child is very young, from birth to about 18 months, their first attraction is to their primary caregiver. The secondary caregivers are added to that, and the child remains firmly bonded to those caregivers until about 9 years of age. This early childhood bonding is important, because that is how children learn about trust: a parent being loving while caring and nurturing the child teaches them to trust. That the parent doesn’t “spoil” the child by over coddling also teaches the child a healthy mistrust that is important to a child’s development. If a person learns to trust others too much, then wind up in unhealthy, dependent relationships and never learn self reliance.

Anyway, the child at age 9 has learned a healthy balance between trust and mistrust, and soon this develops into a sense of independence that allows them the confidence to begin exploring relationships outside of the family.

At that point, children become attracted to (not in a sexual way) same sex peers (usually same sex peers, but there are some exceptions- think the traditional tomboy who played baseball with the boys) who are outside of the household. They begin to emulate those peers, children their own age, plus or minus a year or two. This learning behavior is a normal part of childhood development, and is driven by the fact that humans are social animals.

We emulate the behavior of other humans so that we can enter societal groups and not be outcasts. This normal attraction to same sex friends has been called the “normal homosexual phase.” Homosexual in this case not referring to an erotic, sex driven attraction, but to an emulation of those who would become a child’s social peers. Those of you reading this who are boys might remember this as your “girls are icky” phase. These are the days of summer camps, fishing with your best friend, or girls playing house and dolly. Skipping rocks, making mudpies, and playing pickup games of baseball. This is when children learn traditional societal roles and responsibilities.

There are adults who use this phase as an opportunity to confuse children. It is during this phase that children begin to form friendships and a sense of their role as it relates to the society in which they live. Those adults who want to take advantage of this have a narrow window of opportunity, because beginning about two years later, children begin to show the first signs of sexual attraction to the opposite sex. It is during this “normal homosexual phase” that children are most easily groomed into being confused about their role and can be swayed into accepting a nontraditional role such as transgenderism or homosexuality. The formative years from about 9 to 12 or so is when children form their sense of who they will become. It would be easy for a manipulative adult to convince a child that his deep friendship for his same sex best friend is really some sort of homosexual attraction of a more erotic nature, rather than of a developmental nature.

Children who are emotionally, sexually, and mentally abused or those who receive emotional trauma during these formative years are those who go on to experience mental health issues as adults. This is why allowing teachers to push these alternative roles upon children in the age groups from Kindergarten through seventh grade is so damaging to children.

This is also why there are teachers who are fighting so hard for access to children in this age group. It is access to young children that allows them to build the next generation of adults with misaligned emotional and psychological compasses.

By Divemedic, ago

Medicines to keep on hand

One thing that people who prepare for emergencies frequently overlook is medicine for “routine” medical problems. There are a couple of over the counter medications that I consider to be essential. When you are in a situation where medical care is not readily available, these medications can literally be lifesavers.

Acetaminophen: This one is good for pain and for control of fever.

Benadryl: This drug is good for allergic reactions, and also works well as a sedative and sleeping aid.

Ibuprofen: This is a non steroidal anti inflammatory. Anyone who has ever been in the military will tell you that this drug is used by them for everything from headaches to broken bones.

Immodium: Diarrhea is a killer because losing fluids and electrolytes can be dangerous. In a survival situation, take some as soon as the second incident of liquid bowel movement occurs.

Meclizine: This one is sold under many brand names. It’s good for mild nausea and can prevent vomiting. Like diarrhea, vomiting causes a loss of fluids and electrolytes that can be life threatening. It’s best to take this as soon as you feel queazy. If you wait until you are vomiting, it may be too late. Just remember that it can make you drowsy.

I’m sure that there are others I have forgotten. I am open to suggestions on what you may feel is essential.

By Divemedic, ago

Treating gunshot wounds

This is the written form of a bit of training that I did for the Florida Blogshoot back in March. This is not intended to be a replacement for actual training from a quality instructor. This is a quick summary of what I have been trained to do, trained others to do, and have done during my more than 30 years’ experience as a street medic and educator. This is also not a comprehensive guide to treating gunshot wounds. What this is, is a way to make a difference in a scenario where you are the witness to a person getting shot, first aid, as it were. I hope that it is useful, just as I hope that it won’t be necessary.

You have a limited amount of time to carry out the steps below. A serious wound can cause your patient to bleed to death in less than one minute. If you have the means, practice this skill. You don’t want to have the first time you do it to be when it is needed.

Stop the hazard

When a person is shot, your first priority is to make the scene as safe as you can for yourself, the person shot, and any other rescuers. If on a range, immediately call for a cease fire. If in a violent encounter, return fire. Suppress that incoming, eliminate the others shooting, whatever you need to do to make the incoming fire slack off so that you can get yourself and the victim out of the line of fire and to cover. That includes having the victim fire his weapon at the enemy, if possible.

Call for help. Call 911, call for a medical unit, whatever. You are not gonna want to stay here forever with this casualty. Eventually they will need more care than you can provide. Call for it now.

Quick Assessment

Once the victim is out of the immediate line of fire and help is on the way, do a quick assessment. Where are they shot? How many times were they shot? Are they bleeding? Are the still breathing? If, seconds after being shot, they have already stopped breathing, the OVERWHELMING stats say that no matter what you will do, they won’t make it. Sorry, but those are the facts. Now, if you are not under fire, it doesn’t hurt to do CPR at this point, but if you are in a firefight, performing CPR has just eliminated at least two people from the fight.

If they are breathing, look at where they are shot: the torso, or an extremity? Be thorough. Don’t let the obvious, gruesome wound distract you from one that is less obvious. Don’t overlook the fact that one bullet can leave two holes: an entry wound, and an exit wound. That same bullet can pass through one body structure and strike others. I have seen a bullet pass through a person’s leg, and strike the other leg. Likewise, pass through an arm and enter the chest. Expose the wound area. That means cutting off the victim’s clothes. EMTs are taught to get their patients “trauma naked.” That means strip them down to their underwear (or less, if indicated)

Extremity wounds

If they were shot in an extremity, press a bandage impregnated with a clotting agent (preferably QuikClot, but Celox is also acceptable) to the wound. Press firmly. If the bleeding stops, put a dressing over it, like the Israeli Combat dressing, so that it stays in place. Don’t try to remove the dressing once you get the bleeding stopped- there is a clot there, and we want it to stay in place.

If that Quikclot dressing doesn’t stop the bleeding within 30 seconds, put a tourniquet on the extremity. Quickly. The one that I carry is a CAT. I like them for the ease and speed of use, and I own probably 6 or 8 of these. I have actually used them on people who have been shot, and they work. Place it at least 4 inches closer to the torso than the gunshot wound, if possible. Crank it tighter until the bleeding stops. Yes, it will hurt.

I once treated a woman who was shot 13 times with a 9mm, and had a total of 48 bullet holes in her (some bullets went through both legs). After being shot and left for dead, she crawled to a neighbor’s house and begged for help. I didn’t have enough QuikClot bandages to plug all of the holes, so she got a pair of tourniquets, a handful of trauma bandages, and an air evac. She was rushed to trauma surgery and made a full recovery.

Torso/Neck wounds

If the wound is on the torso (the neck is part of the torso, for this purpose, but the head is not) then you need to be aware of the possibility of air being sucked into the torso. This sets up other problems, so we want to avoid that. Bleeding control is less of a problem, because most bleeding in the torso is going to be internal bleeding that isn’t controlled with pressure or tourniquets.

So in the case of a torso wound, put an occlusive dressing on it. I really like the Hyfin Chest seal. (It comes in packs of two- entry and exit wound, remember?) Just put the center of the dressing on the hole, and press the glue down onto the skin. If the patient has a sucking chest wound, you may have just saved them. If he doesn’t, the occlusive dressing won’t hurt them or make things worse.

The head

So at this point, you might be saying to yourself, “What about wounds to the head?” and that is a great question. Head injuries are tricky, and are even worse when those injuries are caused by high speed projectiles. A gunshot wound to the head is survivable, especially if the bullet doesn’t enter the brain cavity. Many wounds to the face, while disfiguring, are survivable. You can also write a book with all of the things and ways that head injuries need to be treated. I myself have seen a few cases where bullets wrecked teeth, facial bones, and more, but the patient was alive and awake. It can happen.

The main treatment here is to stop the bleeding while making sure that the person’s airway doesn’t fill up with debris: blood, tissue, and teeth can all block the airway and make things tricky. Try to use the Quikclot dressing on facial injuries, keeping in mind that the airway needs to be open.

For God’s sake, don’t use a tourniquet and be careful with the use of pressure because there is a possibility of skull fractures. For that reason, controlling bleeding of the face is a great idea, on the skull, not so much. A person isn’t likely to bleed to death from a skull injury. If a bullet has hit a major artery in the skull, they are more likely to die from other things than they are from blood loss.

As usual, my disclaimer: I have no profit motive or stake in the products that I recommend here. The only reason that I recommend them is because I use them and consider them to be quality products at a reasonable price. I don’t make any money if you buy them, nor does anyone that I know, to the best of my knowledge.

We in the medical field have a tendency to criticize and critique. Before any of my medical brethren take a crack at this post, I ask that you do a couple of things: Review the recommendations of the Committee on Tactical Combat Casualty Care (CoTCCC) and the National Association of Emergency Medical Technicians. They are two of the leading agencies for prehospital care of trauma victims.

QuikClot impregnated Combat gauze is recommended by the CoTCCC and the NAEMT as the first choice for hemostatic dressing of uncontrolled hemorrhage. Celox Gauze & ChitoGauze may be used if Combat Gauze is not available. They worked as effectively as QuikClot Combat gauze in laboratory testing, but neither ChitoGauze nor Celox Gauze have been tested in the USAISR safety model. Chitosan-based hemostatic dressings have been used in combat since 2004 with no safety issues reported.

Since the two largest bodies recommend the use of QuikClot as the first line clotting agent, that is what I recommend when I conduct training.

Remember also that medical doctors and nurses don’t think like prehopsital providers because they aren’t. What happens in the field, especially in situations where bullets are flying, is a completely different kind of medicine than what happens in a hospital.

By Divemedic, ago

First aid

Yesterday at the blogshoot, we did a bit of training on gunshot wounds. Several people in attendance asked me to do a post on the contents of a first aid kit. Let me start by saying that the way paramedics can tell the new guy from the experienced medics is in the amount of gear they tote around. Medics, fishermen, and gun owners have a trap that they commonly fall into, and that is the tendency to buy tons of gimicky crap when it comes to equipment.

Remember that serious trauma is first and foremost a surgical emergency. Trauma patients don’t need a tricked out first aid kit- they need a trauma surgeon. All they need you to do in the field is keep them alive and prevent them from furthering their injury until they can get on the operating table. So with that in mind, I take a minimalist approach to trauma first aid equipment. Please see the end of this post for disclaimers and conflict notice.

First aid kits that are filled with bandaids, sting ease, and other supplies are not good for this sort of work. Sure, I have one of those in the car, but band aids are not going to do you any good with a serious injury. Likewise, don’t get one that has suture kits and everything else, because you aren’t gonna need that and will likely screw it up anyway. Remember: simple. minimal. Stay in your lane.

The basics:

A pair of trauma shears. Most often used for cutting off your victim’s clothes. Don’t bother with the ones that have built in carabiners, bottle openers, glass breakers, or any of that other nonsense. You will likely throw these out once they are soaked in blood, so don’t waste a lot of money on a tricked out pair.

A compressed space blanket. Trauma patients need to be kept warm. After you treat them, wrap them in one. I used to keep the back of my unit heated to 90 degrees for trauma patients. Since we can’t do that, a space blanket is a great way to help with that.

A couple ( 2 or 3) packs of gauze soaked with a clotting agent. QuikClot is best, any of the other commercial alternatives (Celox for example) are acceptable. Many doctors will trash talk QuikClot, but every time one has told me that, the only reasons they can give are anecdotal. The plural of anecdote is not data.

A quality tourniquet. I prefer the CAT. Try to get one with the NSN number printed on it, that way it is more likely to be MilSpec and not a Chinese knock off.

A nasopharyngeal airway with a pack of KY to aid insertion.

An Israeli combat bandage. I like these because they can also be used as an ACE bandage, or (in conjunction with a triangular bandage) to stabilize arm/shoulder injuries, and other uses. Use your imagination.

A Hyfin Chest seal.

A pair or three of exam gloves.

If you don’t want to assemble a kit piece by piece, this is a good one. I just throw out the cheap tourniquet, then add a CAT, a Hyfin kit, and that handles most of what you will need in an emergency.

I follow the CoTCCC (Committee on Tactical Combat Casualty Care) Guidelines (see below) very closely and have designed trauma kit around them. All of the trauma treatment training I conduct is based on those guidelines.

Tactical Combat Casualty Care (Pronounced “T-Triple C”) is a set of guidelines developed by USSOCOM (United States Special Operations Command) to properly train non-medics to deal with the preventable causes of death in the field. With that in mind, remember that the single most important piece of gear that you have is the knowledge that you carry in your head. Seek out and get some training. Do not attempt to do any of this or use any of this stuff without knowing what you are doing.

Supporting documentation from the National Association of EMTs:

Basic Management Plan for Care Under Fire

  1. Return fire and take cover.
  2. Direct or expect casualty to remain engaged as a combatant if
    appropriate.
  3. Direct casualty to move to cover and apply self-aid if able.
  4. Try to keep the casualty from sustaining additional wounds.
  5. Casualties should be extricated from burning vehicles or buildings and moved to places of relative safety. Do what is necessary to stop the burning process.
  6. Airway management is generally best deferred until the Tactical Field
    Care phase.
  7. Stop life-threatening external hemorrhage if tactically feasible:
  • Direct casualty to control hemorrhage by self-aid if able.
  • Use a CoTCCC-recommended limb tourniquet for hemorrhage that is anatomically amenable to tourniquet use.
  • Apply the limb tourniquet over the clothing clearly proximal to the
    bleeding site(s). If the site of the life-threatening bleeding is not
    readily apparent, place the tourniquet “high and tight” (as proximal
    as possible) on the injured limb and move the casualty to cover.

Disclaimers and conflicts:

I have no financial conflicts to disclose, other than the fact that I do make money for training people in various aspects of trauma and medical care. I do not have a financial stake or interest in any of the products mentioned or linked in this post.

This post is not a substitute for training, knowledge, or does it imply that you should practice any of the techniques on this page without the necessary training, experience, and clinical judgement to apply these techniques. The writer assumes no responsibility for anyone who attempts to practice any of the actions on this page without first receiving training in the use or application of any of the procedures mentioned on this page.

By Divemedic, ago