Blow-Out Kit

Let's start with a discussion of principles (real quick) before we get into gear.

Most people that have medical training are taught to remember "their ABC's" These are Airway, Breathing and Circulation -- in that order. Pre-deployment, I went through a VERY good live-tissue demonstration for my medical training that consisted of a live-tissue exercise:
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It's almost common now for combat units, but it is OUTSTANDING training, because your patient can actually die if you fuck up.

In this class, the medics (two SEALs, one Ranger and one Army infantry) gave a lecture on the amount of time it takes to die from suffocation and blood loss. It takes 3-5 minutes even begin suffering permanent damage from suffocating, while you can bleed to death in less than 3 minutes. This meant that the tourniquet was now the number one tool for combat first-responders. We were trained on three kinds of tourniquets:


Combat Action Tourniquet - CAT
(The one we carry out here. Most of them have a place to write the time of application, as well as a red tip to let hang out of a pouch/pocket so someone can help you if you are unconscious. The only problem they had for awhile was the windlass rod was plastic that was easily weakened by the Middle East sun and would snap under pressure. New models have a creamy metal-rod center. The velcro can lose a little integrity due to blood, but most medics I talk to seem to prefer this one regardless.)

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Special Operations Forces Tactical Tourniquet - SOF-TT
(the kind that Feds and Law Enforcement tend to use. I hate these because they are all safety screws and clamps. Seriously, watch the video and imagine trying to do that when you have lost control of fine motor skills, or when you only have one functioning arm. It's a big deal if you are trying to cut off the circulation to a trapped limb. Plus I just don't trust the integrity of that single clamp when it's covered in slick blood)
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Rapid Field Tourniquet - RFT - a.k.a Ranger Ratchet [which must always be said as if you were announcing it was Ridge Racer]
(Oh yeah baby, this is the kind that is retard proof and easily self-applied. Also capable of crushing your bones as Gung-Ho Marines often encountered when in a life-saving-frenzy of mindless cranking. I have never NOT been able to apply one of these for immediate pulse-stopping results. Their only major problem, besides being super-effective against bones, is that they can become stuck with the combination of blood and sand that gun-shots tend to accumulate.)

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Now, most old Medical FM's will say to apply the tourniquet two to three inches above the wound, but anyone who has hunted can tell you where the problem with that arises: bullets are fucking weird. They tend to do weird shit like travel down walls, ricochet off of water at shallow angles and bounce inside of the body. So a respective entry-point at the wrist might conceal a hollow cavern that extends to the elbow (where the round never exited to give away its secret). Placing the tourniquet two inches above this injury will do nothing and you will notice the skin above it swelling and turning purple (because it's filling with blood). Another cause of branching sub-cutaneous injury is the bones themselves splintering violently and cutting veins/arteries.

We were trained that the simplest answer is to apply the tourniquet as high on the limb as possible. This means an inch or two below the hip for leg wounds (to allow the leg to still step if possible) and right below or on the deltoid for arm injuries. This allows you to practice the same process over and over without having to think about placement. An advantage to applying the t-kit high on the leg is that it will partially lock the muscles of the quadriceps in place, which can help the casualty walk if he has to manage on his own.

next post:
Hemostatic Agents

Hemostatic Agents

Most kommandos have heard of Quik-Clot, but fewer have heard of CELOX.

Quik-clot got a bad reputation back in Iraq because it's utter shit: it burns your skin (bad enough that casualties went into shock from the pain), it tended to not work well with people on blood-thinners and medical personnel have to scrape ALL of that shit out before they can properly cast heal on you because it contains synthetic material which has to be removed from your body. It also becomes a very hard mass if left in the wound for longer than a couple hours, making the removal all the more "fun." Also, I heard about a guy that got that shit in his eye. I started cringing at the story.

CELOX doesn't hurt, will help your body to clot on its own (whereas QC uses your body's own clotting agents and accelerated their efficiency) which means it will work just as well even if you are anemic or experiencing hypothermia. It can easily be removed from wounds, but not all of it HAS to be removed (because a lot of the chemicals are essentially sugar based. CELOX can also stop the severe bleeding from a severed artery. In testing by the US Marines, CELOX was the only product to obtain 100% survival.

Rumor has it that Quik-Clot has improved their product, but why trust it?
CELOX is just all-around good shit. Now you can get it in a powder form, or you can get CELOX-infused gauze. Either one is fine really, but it wouldn't hurt to have both.

If the bleeding can be stopped with a tourniquet, then leave it at tourniquet. If the wound is bad enough (or just high enough) that a tourniquet will not stop the bleeding (or you have used all of the casualty's tourniquets already) then a dressing will be required.

If you must pack a wound, the process is:

Locate the closest Major artery to the wound and place your knee directly on it. This will hurt him like fuck, but will stem the blood-flow somewhat.

Clean the wound as best as you can (water rinse, wipe shit away with disinfectant pads if you have them), unroll some gauze and (holding the end) throw the roll over your shoulder. At this point, pour or inject a Hemostatic agent if you have any, and immediately begin packing the wound (try not to have too much time between the hemo and the packing, otherwise excess bleeding will push all of the hemo out of the wound).
Pack the wound tightly with only two fingers at a time, one hand at a time (you're trying to shove as much material into the wound as you can fit, this method allows no air-room). Some wounds can require more than a single roll of gauze. If you first used a packing material with a hemo in it, you will finish packing the wound with normal gauze.
When the wound is over-filled, place your other knee (if feasible) directly on the wound while you prepare the Compression Dressing. That shit needs to be as tight as you can make it (no underage virgin jokes here *halo*). When the dressing is in place, it never hurts go go over it again with an Ace bandage. Now the method for dressing like the Ace bandage is not the same as the gauze: your dressing should ALWAYS be pre-rolled. Some military dressing do not come rolled in the packaging. Roll them. You should be applying the bandage one inch at a time, slowly, focusing on stretching the bandage WIDE to cover as much surface area as possible (if you unroll it and just wrap it around, it will be stretched thin). To secure the end of an Ace bandage, I will split the end a few inches up with a blade and then pull the ends around opposite sides of the limb and just tie them.

NOTE: in the event that two people are working on a patient, while one is preparing the hemo-agent, packing material and compression bandages, the other should try to employ the most readily-available material for stemming blood-flow:



Get your digits in there and try to block the wound. If you can stop the bleeding with your fingers, then that gives you (and your partner) some breathing room to better assess what is going on. Bleeding always comes first.

Brotip: YOU NEVER PACK A TORSO WOUND.
On an abdominal wound, you should use a compression bandage that stretches around the torso.
On a chest wound (which will be covered later) requires a special kind of dressing.

So far, in our Blow-Out kit, we should have the following:
-Tourniquet that you (and your mates) have practiced with
-Roll(s) of Gauze or packs of other packing material (I trust Kerlix Gauze)
-Compression Dressing (extra Ace Bandages are good too, they tend to do best going over a proper Compression Bandage for added pressure)
-Abdominal Dressing (if your other dressing wouldn't be adequate)
-Clothing Shears (to get at those pesky injuries)

Optional Items:
-Coagulating agent (powder or gauze)
-Duct Tape (good method for adding pressure to Dressings)
-Gloves if you want 'em (their usefulness is directly proportional to the strength of your fear of AIDS)
-Disenfectant (unless you are in the bush with no route back to medical attention, infection shouldn't be high on your list of concerns)
-Tweezers or something similar never hurts (discluding the physical pain of pulling shit out of flesh)


Brotip: Although I am including tourniquets in the list of Blow-Out Kit items, they don't need to be IN the kit itself. I keep one attached to the side of the kit, and one attached to my Armor in a location that Either* hand can reach it (center of chest is a good spot; bottom of armor centered isn't bad, but if you are wounded bad enough to be stuck on your back, larger vests [I'm looking at you IOTV] might put it out of your reach; wrapped in the padding-sleeves for the shoulder straps is another good place; calf and shoulder pockets aren't bad locations either)

I had my Blow-Out kit on my vest for awhile, but have realized the merits of having it on my belt over my ass (as that rocket video shows).

Next Post:
Chest wound and NasoPharyngeal Airway

yay tccc training!!!

What about using tampons/pads as gauze etc? Also I heard quickclot can become gangrenous if not removed properly.

ZeeX10 wrote:What about using tampons/pads as gauze etc? Also I heard quickclot can become gangrenous if not removed properly.

Like I said in the post, Quik Clot is bad for you and should be avoided (unless there is no other way to stop someone's bleeding). Celox is much better.


Tampons are good for nosebleeds, but unless the would is a perfect hole (that doesn't get bigger on the inside) some kind of packing material would do better (because it would actually fill the cavity). But again, if that's all you can afford (or have access to in a given situation), I would combine it with some powdered CELOX for maximum win. I can't imagine Tampons being cheaper than a roll of plain gauze though.
It might be worth keeping one or two in your kit just for nosebleeds though (I've had BAD nosebleeds out in the dry air here, because it is super-effective against my Florida gills).

As for Pads, I could see them being used as a makeshift compression-dressing to go over a packed wound (and then going over it again with either an Ace bandage or tape [for additional pressure]).

I'll get to the Naso and Chest-wound soon.

Chest Seal
The biggest concern during a chest wound is air, but not in the way you might expect. The lungs are extremely light-weight organs that will lose against air in a shoving contest. If air is allowed to rest inside of the chest cavity, the casualty can literally suffocate while having no actual lung damage. The medical term for this air in the chest cavity is called a Pneumothorax.

A pneumothorax feels like suffocation with a tease. If you're drowning in water or someone is choking, it's obvious that you're suffocating because these represent a complete cessation of the flow of oxygen (or even if they're not, there is a definite, identifiable external factor exerting influence on you); but if you're suffocating because of the gradual build-up of air, and you already have a bullet wound to worry about, you can pass out before you ever figure out what's going on. If you've never experienced REAL suffocation, then you don't know what you're missing. In the same way you need to know what a tourniquet feels and looks like when employed properly, you need to know what it is like to experience suffocation and also be able to identify the signs in others. Trust me here:

Get a Kommando, Cut a straw in half, you each take a piece, one of you then sprints a good quarter-mile (or whatever will get you to the point of COMPLETE breathlessness), stop in front of Kommando, shove straw-half in face and block nose with hand, breathe through straw.

Your partner should be looking for specific anatomic-feedback. When your body is not getting adequate oxygen, it will begin employing auxiliary muscles to back you up. The shoulders will begin moving in a pronounced fashion and the small muscles of the neck and upper chest will be visibly working. The casualty's face will begin to flush and their pupils will dilate. They will often have jerky movements as well.


The most common Chest Seal is the Asherman, with a large one-way air valve to allow air out but not in. I prefer the Bosin that has three low-profile valves and better adhesive. Either way, you should outline the seal with extra tape. Once the Chest-hole is sealed, you should check for a secondary hole (whether it is the entry or exit is irrelevant, the seal with a valve needs to be on the chest: because you don't lay casualties on their stomach). To seal the back, a good method is to use the plastic the seal was packed in and tape it around the wound. Another ad-hoc solution is to keep a ziploc bag or two in your Blow Out Kit to do the same.

NOTE: Some Impromptu-First-Aid manuals suggest that if you have no chest seal, use the Ziploc method but only tape three sides. This is to allow the expansion of the lungs to slowly push air out, but the sucking caused by exhalation will suck the plastic down and seal the wound. This is fine for people who are unconscious and AWAY from the field, because any dragging, rolling or other manipulation of the patient will crimp the plastic and break the seal of the plastic.

Identifying a pneumothorax in an unconscious casualty requires you to touch the chest and feel for air bubbles. And as weird as this sounds, it feels like rice-crispies underneath the skin. This air's gotta go. If the seal isn't solving the problem, you will need to intervene.

Decompression needles
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They have valves and shit you can fuck around with, but what I preferred in training was basically just Dirty Harrying it: Pull needle from protective plastic, remove the valve on the back and stick'em, then pull the inner piece out.

Where do you stick? On the side with the collapsed lung, identify the second intercostal space at the midclavicular line.
Basically, you start at the middle of the collar bone, imagine a line being drawn to the nipple, count down three ribs and then pierce between that one and the next (just deep enough to where you hear the *whish* of air escaping). If you can't find the ribs because of excess muscle or fat, wing it at around half way down; if you hit a rib, just slide it down until you reach the edge of the bone.

Impromptu solutions are any 10-18 gauge needle (that you can sterilize), that is at least 6 inches long.

Here's a visual for those who need it:
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I remember seeing one of those decompression valves in the movie "three kings", on a side note I have recently become talented at wrapping gauze pads due to an angle grinder taking a chunk out of my wrist.

Nasopharyngeal Airway
Aka. NPA; Naso ; a nose hose


An NPA is a thin plastic tube that is meant to be inserted through the nostril when the patient is having difficulty breathing due to injury or shock. When a person is rendered unconscious, the jaw may relax and allow the tongue to flop back and obstruct their airway. Another scenario is an injury in the mouth or nasal cavity bleeding into the airway. NPA’s create a solid path for air to flow past.
The first, and arguably the most important, step of administering a naso is to remove the clear plastic rod that might be in it. The purpose of that rod is to prevent the NPA from fusing into a solid chunk while in places like the Middle East or Florida. I say this at all because there have been Marines who, in their gusto, have destroyed the nasal cavities of unconscious men by forcibly inserting the NPA.
Now a quick snippet from an EMT:
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“EMT textbook might have explained that the proper way to measure is from the tip of the nose to the ear lobe. True. But you can grab the right size on the first try most of the time with this rule;
Big adults – grab the 8-9mm (24-27 french). Regular sized adults get a 7-8mm (21-24 french). Small adults get a 6-7mm (18-21 french). Kids start at 5mm and work down. When deciding if a patient is “big” or “regular” use their height as a guide, not their weight. Patient height is the most accurate predictor of correct NPA sizing.”
I carry a Naso that works on average sized guys, but Medics may carry several.

The next step is examining the patient’s nose for a deviated septum (a crooked nose, mostly apparent at the bridge). Ideally, two Naso’s would be used if the patient was unconscious, but combat might prevent that for multiple reasons. The largest nostril will be used (whether there is a deviated septum or not).
Make sure the head is tilted back (something might have to be placed under the rear of the neck) like how your head is when it hangs off the side of the bed. Inserting the NPA requires lube. Medics might have medical lubricant, but the rest of us will rely on the time-tested, goin-in-dry approved medium of reduced friction: spit on that shit.

Like so many other times I’ve said this, the insertion is a art. You basically look at the way the Naso curves, and imagine how the nose curves up and into the back of the head.

Now turn it 90 degrees (with the flared end toward you). As you push it in, twist it into the correct position (small wiggles are sometimes necessary). If the patient is unconscious, and you have extra Naso’s (never use yours on someone else), feel free to insert a second one.
The sensation of having one inserted is an extremely uncomfortable, burning sensation, but it’s not something I couldn’t still run with.