MEDICAL: Ottowa Ankle Rules - Are you hurt or injured?

MEDICAL: Ottowa Ankle Rules - Are you hurt or injured?

In a wilderness survival or tactical environment how can you tell if you’ve sprained or broken an ankle? The distinction may seem minor, but the implications are dramatic. In a wilderness environment it means the difference between wrapping the ankle and the patient can walk out, or immobilizing the limb and carrying the patient out. Tactically, the distinction is the same, but instead of having another shooter, you have a casualty.

MEDICAL: The SOL-IFAK

SOL IFAK
SOL IFAK

James G's SOL - IFAK

Over the past decade of working as a contractor in shit-holes around the world and living and traveling in the 3rd world one thing I have always learned to have close by is an IFAK.

Depending on what sort of gig I am on or where I happen to be traveling “IFAK” can mean anything from a backpack packed to the brim with medical kit to a cargo pocket with some QuikClot, some tissues and a Band-Aid.

Basically if you are an operator working in the worlds hot-spots you need to understand that your IFAK needs to be customized to whatever operation you happen to be on. That can be everything from looking from some rich guys missing kid in Bangkok to running PSD missions in Afghanistan.

The particular IFAK I am going to go over today is one of the ones I currently use as a TL running missions (everything from PSD to Convoy Security) for a private security contractor in Iraq.

This IFAK was put together by our Company Medic to be used in a very specific situation. Without giving away any OPSEC shit, lets just say we are way squared away when it comes to having the best medical supplies and highly trained US medics on our missions. So basically if someone (hopefully not the medic) is injured we have not only the medical kit to treat them but also a top tier medical professional on-board.

I call this particular IFAK the “SOL-IFAK” – meaning if I have to reach into it, it is because I am a combination of injured, unable to physically move from my position, cut off or pinned down and my teammates or medic can’t get to me and I have to treat myself ASAP.

It is not for helping others (but it still has the components to do so if necessary), not for treating myself quickly and running to our medic - it is a you are all alone and “Shit Out of Luck” with half your leg 4 feet away along with a few holes in ya type of IFAK.

Pretty much the only time the SOL-IFAK will get reached into is if I am lying on some shitty Iraqi highway, bleeding, pinned down behind some broken down eighteen wheeler that is 12 flatbeds away from my guntruck/teammates and I am not expecting medical assistance immediately.

The SOL-IFAK will keep me alive until my team kills everyone and the team medic is able to treat me and then gets my ass off the X and on DBA.

Note: All the items in my SOL-IFAK were selected by (Call Sign: KeyWest) a highly experienced PSD/CSD Civilian Security Contractor Combat Medic who is a former U.S. Army Medic, Civilian firefighter and EMT. Descriptions and why those items were chosen were written by him, so thanks to 'KeyWest' for helping me with this article.

security contractor IFAK
security contractor IFAK

SOL-IFAK Contents

Let’s start from the beginning… basic first aid. Apply manual pressure and elevate. Next dress wound. Next apply a pressure dressing. Next, apply a tourniquet. These have been the basics of first aid and how it has been taught from the beginning. However, there are now some different options to keep close.

Cravat
Cravat

Cravat

The first most basic part of this kit would be a cravat. This can be used as a sling, for a pressure dressing, to be used in conjunction with a splint, and as a tourniquet. We carry at least 2.

Field Dressing
Field Dressing

Field Dressing

The next most basic part is the field dressing -2. This can be used to be applied to stop bleeding, cover a wound, decrease chance of infection, and can also be used in conjunction with others at the same time.

One thought to keep in mind is that one field dressing will usually hold about little less than a pint of blood. This is important to understand because your blood will keep you alive. If your first field dressing has soaked all the way through it’s past time to move on to the next step.

quick clot combat gauze
quick clot combat gauze

Quick Clot (Two Types)

Now on to quick clot. This item comes in different styles. We carry 2. The quick clot combat gauze and the quick clot (ACS) Advanced Clotting Sponge. The regular quick clot combat gauze is for temporary use to control traumatic bleeding. This means major bleeding.Don’t use this if you scratch your knee, or scrape your elbow.

This is for major trauma. You would open the package and apply to open wound and apply pressure for at least 3 minutes. Sometimes you may have to use more than one. At this point you would wrap and tie the bandage to maintain pressure on the wound and evac as soon as possible.

quick clot ACS
quick clot ACS

Quick Clot (ACS

The quick clot (ACS) is for a little more traumatic wound and is used for emergency external use only. This package also reads “Do Not Eat”. I’m not even gonna ask why that is printed on this package.

You need to wipe away any excess blood around the wound then pack the wound with the mesh bag in the package. Sometimes it may require more than one. It’s important to remember that direct pressure over the wound is never forgotten. Apply pressure for at least 3 minutes. This product will produce heat to be aware.

Wrap and tie a pressure dressing over the wound and evac as soon as possible. It’s also important to put the package in a pocket or stuck on you somewhere so medical staff will act appropriately when you receive hospital care.

Emergency Wound Dressing
Emergency Wound Dressing

Emergency Wound Dressing

The next part of our kit is the Emergency Wound Dressing….its a hemorrhage control compression dressing. It has its own device that enables you to one handedly apply pressure to a wound while dressing the wound.

Abdominal Dressing
Abdominal Dressing

Abdominal Dressing

Our next part of the kit is a small abdominal dressing. This is used like any other field dressing except its bigger to cover those exposed guts. And at this point, you might as well kiss your ass good bye because you have a very short time to be at a hospital.

Wound Dressings
Wound Dressings

Wound Dressings

The next 2 wound dressings are elastic in nature and provide pressure when applied. However the sponge is not as thick so other dressing may be required. One thing I’d like to point out is that once a bandage is applied…. Never remove it. Just keep adding to it.

One Handed Tourniquet
One Handed Tourniquet

One Handed Tourniquet

The next hemorrhage control device we carry is the one handed tourniquet. It’s always nice to be able to stop a major blood flow in a second and stay alive, rather bleed out from a leg blown off. Tourniquets should be the last course of action.

Apply a T on your forehead and note the time if possible. At this point shock will start to come into play and you may be unable to function. But with training, focus, and determination you can apply a tourniquet to yourself.

ARS Needle decompression
ARS Needle decompression

ARS Needle Decompression

Another part of our kit is a ARS Needle decompression. Once you are shot in the chest you thoracic cavity (your chest will start to fill with air… maybe blood. The needle decompression can be used to expel the air and allow your lung to function as best it can.

Remember to roll to the injured side. This will allow your good lung to function as best it can for as long as it can.

HYFIN Chest Seal
HYFIN Chest Seal

HYFIN Chest Seal

The last part of our kit is a HYFIN Chest Seal. This is an occlusive dressing. It is placed over the wound and will not allow air to enter the chest cavity and will allow air in there to escape.

One point to examine here… many chest shots have exit wounds. You are not gonna be able to apply a chest seal to both. Its only if you have and entry point. At that point, lay with the injured side down and apply the resources you have.

JG-FAK
JG-FAK

Thanks again to my Team Medic for helping me with this article

If you have any questions please feel free to jump in on the comments

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~James G Founder – Editor in Chief

JamesGrey
JamesGrey

James G is a Veteran Civilian Contractor who has worked in the Middle East and Southeast Asia for way too long. He spends his off time in Indonesia and Virginia getting drunk, shooting guns, writing poorly written articles and trying not to get shot, blown up by an IED or the clap

MEDICAL: Ditch Dentistry

Austin_Powers_article
Austin_Powers_article

First the disclaimer.  What follows is for informational purposes only.  Nothing should be construed as dental advice.  Without a proper diagnosis by a qualified dentist, appropriate treatment cannot be recommended.  If you find yourself in the midst of a dental emergency/urgency, seek care from a qualified dentist as soon as possible.  If you read this and then think you are an expert, you are the author of your own demise and it’s not my fault.

No one wants to think about dental emergencies when "out and about" but emergencies happen nonetheless.  There are many possible scenarios that qualify as dental emergencies, and unfortunately, there are some things that just simply can't be properly treated in the field.  There are other occurences, however, that do lend themselves to "ditch dentistry" to hold you together until you get back to a dentist.

Prevention is easier - "Going For The Gold":

I have accepted the fact that no one likes to go to the dentist, I don't even like to go to the dentist.  When working/living/traveling in hot zones, the open ocean, jungles, or other far away places, however, it is far better to have definitive dentistry completed prior going to your gig.  The last thing you want to deal with is a dental problem especially a dental problem that could have been prevented.

Definitive dentistry does not necessarily mean that you don't have any new cavities and you've had your teeth cleaned.  Definitive dentistry means utilizing crowns, inlays, onlays, bridges, etc. to treat the teeth as comprehensively as possible to get the longest lifespan possible out of the teeth and the restorations.  This treatment is more expensive and more extensive than simple fillings, but if it is done properly, it will be worth the investment.

Just to make my point as clear as possible, I have five patients who are dentists themselves.  They had me replace their old fillings with gold crowns, inlays, and onlays.  I have had my fillings converted to gold inlays as well.  The gold standard is the gold standard.  It is my opinion, but it is also what I put in my own mouth, you cannot beat gold.

There are prettier restorations, but when it comes to functionality in the field, with lowest probability of failure, gold is where it's at.  I made sure mine were solid before I moved to Honduras to do our NGO work in the rural interior of the country.  You do no one any good if you are taken out of commission, or if your awareness is diminished because your teeth hurt.  Also remember to not wait till the last minute to get things squared away.  There are complications that are possible and you want to be sure you are stable before taking off to the four corners of the globe.

Broken-tooth
Broken-tooth

There are many variations when one considers a broken tooth.  Sometimes it is as simple as a small chip on the corner of a cusp, other times it is a through and through split that goes into the nerve and below the bone.  In the event a tooth is fractured, and the fractured component comes out, keep it if possible.  Not all pieces can be re-bonded to the tooth, but sometimes they can.  Since there is no way to know, without consulting a dentist, keep what you can.

If a tooth fractures beyond a small chip, significant symptoms can develop.  Exposed dentin (the hard yellowish inner component of a tooth) will be solid tooth structure to which a new restoration can be bonded or cemented, but it can be very sensitive, especially to cold and sweets.  If you have a fracture and you notice sensitivity to stimulus, you may have to moderate what you eat/drink and the temperature of it.

If you are out for an extended period of time, you will hopefully have brought a tooth brush and tooth paste with you.  Under these circumstances, I recommend that folks use a desensitizing toothpaste as their normal toothpaste.  There is a chemical that actually does help reduce dentin sensitivity in the toothpaste and if you already have it with you, it will do its job and start reducing the discomfort (notice I said reduce, not eliminate).

I actually carry/use a toothpaste made by Colgate that is called Prevident 5000 Plus-Desensitizing.  This is a prescription level toothpaste due to the fluoride content, but it is the most effective desensitizing toothpaste I have found to date.

If a fracture extends into the nerve of the tooth (also called the pulp) there will many times be significant pain on biting pressure and many times significant sensitivity to temperature and sweets.  Depending on the severity and extent of the fracture, the treatment could vary between a crown to extraction of a tooth.  Unfortunately, there is no easy temporary fix.

If a tooth breaks and doesn't hurt, don't assume nothing is wrong.  As soon as is feasible, get to a dentist to have it evaluated.  Many times a fracture occurs due to a large cavity having undermined healthy tooth structure.  The fracture can be a shot across the bow that is giving you one last warning before it blows up into a big big problem.

Toothache
Toothache

The majority of the time when a toothache develops, it is because decay has extended to the nerve of a tooth, or the nerve has died for some reason.  When this occurs, infection and abscess set in.  There are treatments that will help to alleviate the pain and infection, but the only way to stop it once and for all is to have the tooth properly treated by a dentist.  Treatments in these circumstances vary between root canals and extraction.

If the abscess is severe enough (lots of facial swelling), it can actually become a life threatening medical emergency and surgical drains may be required.  About the only thing that can be done, without definitive treatment, is to try to fight the infection back for a temporary reduction in symptoms.

The drug of choice for treating an abscess is Amoxicillin.  If a patient is allergic to the pennicillin family of antibiotics, I generally recommend Zithromax.  I will repeat that these do not eliminate symptoms completely and they do not cure the abscess, they just take the edge off until it can be properly treated.  Some common dosing regimens for Amoxicillin are 500mg capsules three times per day for seven to fourteen days.

I prefer Amoxicilling 875mg tablets twice per day for seven to fourteen days (fewer pills to deal with and easier to remember to take your meds when you wake up and when you go to bed).  Zithromax 250mg should be taken as follows:  Two tablets on the first day at the same time followed by one tablet per day for the next four days.

fillings
fillings

If a filling or crown (cap) comes loose, there is no permanent field solution but you can use the drugstore emergency temporary filling kits to fill in the hole or get the crown to stay put until you can get to a dentist.  If the filling or crown came out due to a cavity forming around the old restoration, these filling kits may be limited in their effectiveness (go back to the PREVENT problems section at the beginning).

Once again I will say that you need to get to a dentist if a filling or crown are lost as soon as possible, even if it doesn't hurt.  There could be bigger problems looming.

missing-teeth
missing-teeth

In the event of a traumatic loss of the tooth (knocked out completely for whatever reason) and the root is intact, the options will be limited.  If you are able, put the tooth back in the socket from which it came or put it in a cup of milk (yeah I know everyone is always carrying milk with them).

Do not scrub the root of the tooth and if you must, just rinse the root of debris with clean water or milk.  There is a chance it can be re-implanted by a dentist, but this all needs to happen in a matter of hours at the most.  If you are too far away from a dentist and/or are not going to be able to seen rather rapidly, you will not get the tooth put back in and you will require other treatment to replace it in the future, after you heal up a bit.

In-the-ditch-and-you-have-to-pull-a-tooth
In-the-ditch-and-you-have-to-pull-a-tooth

If things have gone very south and you are in a position to need to extract your own or someone else's tooth, your day is going to suck and I'm sorry.  The old ice skate/tooth/rock combination made famous in the move "Castaway" is not to be confused as a tutorial.  I would recommend looking over the shoulder of a dentist/oral surgeon and getting a few pointers BEFORE this becomes a necessity, especially if you think you may find yourself in the position to have to do it (medic/permanent remote NGO worker).

You may also want to get the book "Where There Is No Dentist," published by the Hesperian Foundation.  For what it's worth they also publish a book titled "Where There Is No Doctor" which is excellent as well.  Youtube also has ample videos of dental extractions so you can get an idea of what is involved.  Some are educational, some are friends wanting to be sure the moment was captured for all eternity, either way, the teeth come out.

Dental-emergency-extraction-kit
Dental-emergency-extraction-kit

Dental emergency extraction kit:

I will not go into technique here (it would take a looooong time to put that into words) but a basic backpack emergency extraction kit that I carry into the bush consists of:

- Dental Syringe - 30 gauge short dental needles (5) - 27 gauge long dental needles (5) - Dental cartridges of anesthetic 2% Lidocaine 1:100,000 epinephrine (10 cartridges) - 2x2 gauze (30) - Dental Bone Currette - Small straight elevator - Large straight elevator - 150 Forcep - 151 Forcep -23 forcep - Hemostat - Needle driver - 4-0 Chromic Gut suture with cutting needle (two packs) - Suture Scissor - Alcohol wipes (just to clean instruments after an extraction, this DOES NOT sterilize instruments)

If I am planning on doing lots of dental work (like with our NGO work) I obviously will have a much bigger list of equipment that will do lots of stuff, but this is a decent minimal list for a medic to have on hand.

I hope you are never faced with any of these scenarios, but  if you do find yourself in the unenviable position of having a dental emergency, I  hope some of this info can help put you on the right track to getting out of pain as quickly as possible.

DVM Recommends the Following Emergency Dental Supplies:

Where There Is No Dentist (Book) >>>

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~Dr. David Sperow Dental Medicine Correspondent

dr dave
dr dave

David is a US based dentist that works through La Cima World Missions to lead medical and dental relief teams to Honduras and Southeast Asia.  Prior to founding La Cima, he and his wife ran a small mission clinic in the mountainous interior of Honduras in 2001 and 2002.

ADVENTURE JOBS: Medic 101 - How to Become a Medic

Let’s talk about the civilian route first. This is how I initially got involved with pre-hospital para-medicine way back in 1986. First, a little background info. There’s an organization called the National Registry of Emergency Medical Technicians (www.nremt.org) that has, in conjunction with the Department of Transportation, set national standards for emergency medical responders.

MEDICAL: Safety Pin Airway

Safety pin airway – Iraqi style!
Safety pin airway – Iraqi style!

The Safety pin airway – Iraqi style! (Sweet unibrow dude!)

Read THIS so you can't sue us

Treating a trauma casualty was briefly mentioned in Andrew R.’s First Aid Kit article, and we’ll make sure to post more thorough discussions here in the future on how to treat all things trauma.

In Andrew’s article he introduced EABC (exsanguinations, airway, breathing, circulation), and briefly discussed treating life-threatening bleeding. The next step in the trauma assessment is ensuring the patient has a patent airway.

Unless the airway is blocked due to a foreign object (debris, broken teeth etc), the main cause of an airway blockage is the tongue relaxing and blocking the airway. So opening an airway simply involves removing any object that is blocking the airway and making sure the tongue is out of the way.

Oral pharyngeal airways are designed to pull the tongue up and towards the front of the mouth, ensuring it doesn’t slip back and obstruct the airway. The downside with oral pharyngeal airways is that they have to be sized correctly to the patient, so you have to carry a half-dozen or so.  In addition, if the patient should regain consciousness or is semi-conscious, they can trigger the gag reflex.

Oral Pharyngeal Airway
Oral Pharyngeal Airway

Oral Pharyngeal Airway

And while they are fairly light, relatively inexpensive and simple to use, they take up a lot of precious space, and should, in my opinion, be reserved for an ambulance or in a dedicated medical or squad trauma bag.

Nasal Pharyngeal Airway
Nasal Pharyngeal Airway

Nasal Pharyngeal Airway

The other standard airway is the nasal pharyngeal airway, which, while should be sized in the ideal world, you can get away with only having one in your kit (preferably sized for you), and they don’t trigger the gag reflex.  You should absolutely have one of these in your FAK (First Aid Kit) and know how to use it.  I’ll dedicate a future article to their use because of how important they are.

But sticking with the theme of ditch medicine, if you don’t have a well-thought out FAK (so no purpose built airway) on you and you need to secure the airway of a casualty, here’s how you can do it.  Most off-the-shelf first aid kits come with a triangular bandage (cravat) in them.

The triangular bandage is a piece of thin cloth that is triangular shaped and typically comes packaged in a plastic bag with 2 safety pins. It has many uses including making a sling or sling and swath (if you have two) for a broken arm or some other arm/shoulder injury that you want to immobilize, as a hasty tourniquet, or to tie splints to broken limbs.

cravat
cravat

Cravat - handy for splints and airways

You can take one of the safety pins that come with a triangular bandage and use it to pin the tongue to the lower lip.  This will pull the tongue forward and secure it from blocking the airway.

Obviously, this isn’t the preferred method, and you’ll have to be careful that the bleeding from the now pierced tongue doesn’t obstruct the airway (a gauze pad should do the trick).  But it will free up your hands to take care of any other tasks that you need to accomplish.

Tongue_piercing_fun
Tongue_piercing_fun

Replace the safety pin with a stud and you’ll have given a perfectly cool tongue piercing.  If you’ve got a buddy who snores, pinning his tongue to his lip will help solve that too.

I will say that the safety pins that come with the triangular bandage are about the perfect size for someone with the hands of a 5 year old girl, so I replace them with some bigger ones.  But safety pins are pretty handy things to have around, so I always keep a couple of extras in my kit anyway.

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~John B Cheif Medical and S&R Correspondent

lifeline
lifeline

John B has been an EMT for 18 years and is currently a Field Team Leader for a Search and Rescue Team, he also holds a Master's degree in Neuroscience.

MEDICAL: Putting Together a First Aid kit

I started thinking, as summer is coming up, just what I want in my first aid kit for the range and any firearms classes I will be attending. Then I tried to decide what would be a good kit for just about anything I would do outdoors that might cause a good traumatic injury. I thought about what we had at work (local fire/EMS department) and what changes have come along since the wars in Iraq and Afghanistan.

MEDICAL: Ditch Medicine - Wound and Infection Management

Wound care away from the hospital is always a problem. And thanks to Bear Grylls, everyone thinks that any cut or scrape in the wilderness is going to lead to gangrene and amputation. While antibiotics are often tough to acquire in any decent amount to treat a seriously infected wound, here are some steps that you can use to prevent that field amputation.