PLEASE NOTE that this article contains graphic and disturbing images.
This is the second installment in our series on how to treat a gunshot wound. For part one, click here.
How to Treat a Gunshot Wound
First things first, we discuss the necessary gear to take care of these issues. So I am going to discuss the items you need for your trauma kit. I am only going to address the trauma stuff associated with gunshot wounds. When you purchase a brand new first aid kit, open it and look at all the contents. Ask yourself “Can I replace some of these boo-boo items with true trauma gear?” and the answer is always yes.
Boo-boo items are the six sizes of band-aids, the 1×1 gauze, the 2×3 gauze, the ½” tape roll, etc.
Trauma items are designed to make pressure and absorb much blood. So what we want is 1” tape, and lots of it, 4×4 gauze, roller bandages, triangle bandages, and abdominal pads, designed to cover the entire abdomen if it is ripped open.
Keep the boo-boo stuff and place it in the shooting kit under the first aid area, keep the trauma stuff for a gunshot wound or very serious stuff. I will include a list at the end of this article of what I think should be in the trauma kit. This is not the perfect kit, but it will start you on your way.
The pictures we include here will show the use of the trauma gear, and I believe that it will make more sense to show its use as I explain in written detail.
Communications with HELP
Let’s spend a few minutes talking about getting help to you and yours in the middle of this very serious crisis.
First, make a plan, and part of that plan is to know before a gun is unloaded from the truck, etc. if there is cell phone coverage in that area. You must be able to call for help if needed. If there is no coverage, and no way to call for help, a plan of what to do is a must and should be discussed with every person on that range.
Know the GPS coordinates for a Medical Helicopter and local names of landmarks and areas for dispatch to send Ground Ambulances to you for help. If you are very remote, the ground ambulance and rescue crews can use the GPS coordinates as well.
After we make a plan, everyone is aware and understands that plan, then write down the GPS coordinates, and place them in the trauma kit. Do not rely on the cell phone to be able to read the map coordinates and talk to dispatch or whatever the plan is. It may be nearly impossible to have the caller making sense of all of this with a victim suffering an abdominal gunshot and screaming their head off in pain. Just write it down.
Application of Aid to the Gunshot Victim
In this section I will cover the areas of injury treatment. This should keep it all tight and easier to cover in detail.
With compromised bone tissue, the only thing we will have available for us in the field will be splints, and the gear required for splinting.
Let us discuss the types of splinting materials at short length. There are two basic types of materials that we use in splinting, hard and soft. Hard splints are talking about sticks or commercially made splints that are a fiberglass stick, with padding. For field expedient applications, Cardboard or SAM splints are considered hard splints. They are considered hard splints due to pressure they can apply if secured too tightly.
Soft splints are pillows and blankets; these best used for ankles, due to the conforming aspects of the materials. Don’t let a pillow or blanket fool you, if they are placed directly on the body, taped like you mean it, they will give excellent support. The issue with soft materials is they can be very cumbersome and take up massive amounts of space when talking about field items.
In the list, I provided it has cardboard splints, easily made by the shooter and placed around the outside of the shooting kit to make form and structure, and keep the cardboard out of the way. The other is a S.A.M. splint. SAM splints are a piece of aluminum covered with padding and rolls up the size of an elastic bandage when new. I have no idea how they do that from the factory, but when rerolled, they are still very compact. The SAM Splint has a unique application: it can be contorted into any shape, like cardboard, and then a crease is placed down the center. The crease will take a thing about as rigid as soda can, and make it hard as a rock. When some serious tape, like duct tape, is used, it will be very ridged, and good for transport of the victim.
The same can be said of cardboard. Very light weight, shapes to fit, easy to cut, and after it is placed, then taped like you mean it, rigid like a plaster cast.
I strongly suggest keeping both handy. Trauma shears will cut both of them, impaled objects are accommodated if needed, and digits can be left exposed to check for circulation, etc.
One thing that I don’t see covered much when reading about splinting is what if the area is an open fracture, meaning the broken bone has punched through the skin. The term compound relates to the issues of the break, so we have bleeding and broken stuff to deal with. If the skin in open and the bone is broken or could be broken, it is treated as a compound fracture.
The bleeding issue is always addressed first, and the splint is NEVER applied until bleeding stops. This is critical.
After the bleeding stops, the splints are applied. Do not apply the rigid splint surface over the knots used to secure the bandaging, this will create a tourniquet effect. If the tape is used to secure the bandaging, then the rigid splints can be placed where they are most effective.
If we have massive tissue damage, use the splints to keep the wound from becoming worse by contracting or stretching tissues that are clotting. Splinting works well for a small laceration becoming a big laceration from tearing of the tissues.
If a splint is applied, we need to check for blood flow to the rest of the tissue so that a simple test can be used. Pinch the nail bed, farthest away from the splint. The nail bed will blanch out, then release the pressure, and the color will return. Called Capillary Refill, it tells you and the responders that blood flow has not been cut off from the rest of the limb.
Now we get into the meat of the subject (yes, pun intended).
The main and nearly only word that we need to think of when dealing with soft tissue injury is pressure, direct pressure. Without it, we will lose the battle. Think of pressure like this, how do we stop a hose from running, without using the valve, of course? Do we cover the end with a towel and hope it will absorb all the water and keep it from flowing out? Do we step on the hose and the water is stopped by the pressure on the hose?
Direct pressure, is what will stop the blood flow. The body will then attempt to stop it with clotting. If the injury is too great, the clotting will not be effective, so the pressure must be the deciding factor. The dressing, (the gauze against the bleeder) its job is to give the clotting a matrix to start working in. The dressing also keeps all the nasty from the outside world from getting into the open wound. The bandage, (the wrap that applies pressure) its job is to free your hands to do other things. So if you need to squeeze the injury like you are trying to choke a brick to stop the bleeding that bandage needs to do the same. If you need to use your knee to stop the bleeding, the bandage needs to do the same.
So, before we carry on with pressure bandaging, the point comes up about so much pressure the capillary refill stops. If the bleeding is that great, the pressure is applied, and blood flow to the rest of the limb stops, that creates a tourniquet. If it will take that much direct pressure, then apply the tourniquet. We will cover this shortly.
Pressure bandaging can be a daunting thought. It is more simple than you think, it is to just wrapping a bandage around the area, then pulling it tight until bleeding stops, it is placing direct pressure on the bleeding tissues. So, if you think about this, if I use a tennis ball to apply pressure to one spot on the arm, that spot is compressed, the rest is normal.
That is exactly how pressure bandaging works. Here is the place a first aid misses the mark, we all heard it, direct pressure until our ears bleed. But how do we practice applying direct pressure, with the general pressure, so our minds are programmed to wrap the area, pull the bandage until the whole area is squeezed.
So, now that we understand direct pressure let’s talk about gaping and nasty wounds.
Think of a gunshot channel and the massive tissue damage of the exit wounds. How can a dressing covering this area on its surface, stop bleeding in a hole that may be 3 inches in diameter and 5 inches deep? The horrible answer is it cannot. That gaping hole will continue to do nothing more than fill up with blood and leak blood internally and externally until it eventually stops. Two things will stop it, direct pressure or the victim runs out. The second is not a good option for a good guy anyway.
So what do we do, we just talked about the tennis ball approach, so if it is needed in a gaping hole of a gunshot wound, we put it there. Now, do not jam a bunch of 4×4 gauze pads into the wound, they may not all be found at the hospital. Use the big, huge pads, or the roller gauze, get the dressing to the bleeding. Then wrap the bandage around the area, or if wrapping is not a choice, use the tape, again “like you mean it”.
To make a very direct point, good looking wrap jobs, and awesome and perfect alignment splint jobs are cool to look at, and cut off 20 seconds after they are taken to the ER. After the doctors fail to admire the perfect wrap job they thrown on the floor. What is needed is, pressure = blood flow stops. That is all that matters, never worry about what it looks like. Worry about did it work, or not, if it did not, apply for bulky dressing over the wound, and put on more pressure.
Now to talk about tourniquets. Once upon not long ago, we never used tourniquets, they were avoided like the plague. Then more research has been done, and, unfortunately, our current wars on terror have been the leaders in this field. The muscle tissue can withstand a tourniquet for 2 hours before tissue damage is beyond help from vascular surgeons and new and improving treatments.
The quick and dirty answer to tourniquet application is = if they need it, use it. It is very few places in the United States that cannot be reached by helicopter in an hour and deliver the patient to the surgeons in the next hour.
If the victim is bleeding so heavily that direct pressure will not stop the bleeding, they will not be alive to see the surgeon if we don’t use the tourniquet right away.
We have some new products in the EMS world when it comes to tourniquets the military style I believe the best design, tough as it can get and simple to use. The old school way of using a triangle bandage, and a stick works just as well. The one thing to remember is to use a wide area, about 2 inches to keep the tissue damage at a minimum from the tourniquet band. Secure the stick so nothing but a pair of shears will get it to release.
The pictures will demonstrate the proper application of these subjects, better than over wordy descriptions. A proper class on trauma is the very best way to make sure you are ready for this situation if it ever happens to you or those around you.
There are some clotting agents on the market; again we give our heartfelt thanks to the veterans that became the subjects in this testing during the war on terror.
The clotting agents are excellent at stopping the bleeding. The issue with them is they have to be cut and scrubbed out of the wound before any surgery can is performed and may inadvertently make the injury worse. Think of this, clotting agent works kind of like Kitty Litter. If it needs kitty litter to stop the bleeding, then use it, but all of that litter has to be scrubbed from that wound. And kitty litter does not bind to the tissues like these clotting agents, so more cutting or scrubbing is needed for them. Clotting agents are designed for field expedient care while under fire, and a very long wait for transport, possibly days.
I suggest having this in your trauma kit, but you must know how your clotting agent is designed to work, read the instructions, and visit that manufacturer website to learn everything about it.
Again, like tourniquet use, if direct pressure does not stop the bleeding, you must take it up a level, maybe the use of this clotting agent is the best thing for the situation. There is no way to cover every “what if” here, so you need to make the plan ahead of time. When would you use this intervention vs. that intervention, do not try and “wing it”, that is a good way to fail in a very stressful situation, make a plan.
Unfortunately, there is nearly zero we can do about solid organ damage in the field situation. There is little that can be done by the first responders; it’s the surgeons that make the difference for these victims.
So our duty will be to recognize that massive damage could have reached the organs, and get help on the way ASAP. Make sure the responders have the correct location and easiest methods of finding the victim.
When the hollow organs in the abdominal cavity are damaged, unless they are hanging out ( later) we have nearly zero ability to help these victims as well.
If the hollow organs are in the chest cavity, we may be able to provide some help. If the entry and exit wounds are allowing air to enter the chest, everything will get into the body. So we will need to sue the occlusive dressing. Occlusive dressing just means that air cannot get through it.
If the wound is making a sucking noise, air is leaving the chest and entering the chest, we need to make very quick action to keep the air pressure from the leaking lung from building up inside the thoracic cavity.
We use the occlusive dressing for either, keeping air from reentering the chest cavity, and to allow air to leave from the inside and not to allow it to be sucked back in.
Place the occlusive over the injury, and tape down three sides, the pictures do a better job of description that worlds will. This will allow air pressure from the thoracic cavity to leave, it will work like a “flapper valve”. When the air is trying to be sucked back into the chest cavity, the occlusive will pull against the wound, and stop the air flow.
The EMS world also has a piece of equipment for this; it’s called a chest seal. These are priceless for dealing with gunshot wounds. They are an all-in-one unit, they will adhere to the skin, and the “valve” effect built in, and works nearly perfect. Nearly perfect, because in EMS nothing ever works perfectly for every situation.
For hollow organs that are hanging out of the abdominal cavity, this is called an Evisceration.
Eviscerations are very shocking, even to watch a movie; they make everyone cringe away.
Filed treatment of evisceration is a matter that needs immediate care. The organs are not pushed back into the body. The exposed organs need to be kept wet, warm and sterile – as much as possible. Place a large gauze pad over the organs, wet it with the cleanest water available to you. Then cover the entire thing with the occlusive dressing to keep the gauze from drying out, and to keep the area clean. Tape all the sides down, so things don’t leak out or crawl in, and, of course, get help to you ASAP. The exposed organs can die as soon as they dry out, and the victim right afterward.
In closing, I cannot stress the importance of good, high-quality trauma training is for shooters, for any level of the sport this skill set is needed. Find a high-quality training near you. Take an EMS class and get your certification. It is the best money your will ever spend, and this subject is just a sliver of what you will learn, and be ready for if it ever happens. Not all EMS people work in the field, there are many that have taken this training and had it as a preparedness skill, and I can whole heartily agree.
If this ever happens, and you find yourself stuck in neutral, just start doing something, the answer ill come to you. To make sure that neutral thing never happens, make a plan, get the training, and be readier for it to happen than you may think you need. Remember the beginning of this article, the caller was sitting on his couch, not on the firing line, not hunting, just watching TV, and it nearly cost him his life.
Don’t be a tragedy, be the difference!