After The IFAK: Part I
Combat medicine is a woefully under-documented field. While plenty of articles offering advice and packing lists exist, rarely does medical writing for the gun community involve much past what you should have in a pouch. While these skills, the underlying assumption that is the common thread for all such instruction is that “there is someone else coming.”
But what if there isn’t?
In the “After the IFAK” series I want to detail what the average /k/ommando can do to continue providing medical care for wounds encountered in non-permissive or austere environments. This field of study is known as Prolonged Field Care (PFC). Tourniquets need to be eventually loosened, infections constantly battled, and pain eventually managed. The materials and skills I will attempt to cover will include items the average /k/ommando would have, in keeping with the idea that you’re on your own. Part I will cover tourniquet conversion, often the first step in our process.
Conversion is the deliberate process of trying to exchange a tourniquet for a hemostatic agent or a pressure dressing.
The tourniquet is often the most expedient and effective way to control a life-threatening bleed. However, the prolonged application can result in many issues. Compartment syndrome, permanent tissue damage, and perhaps the most dangerous concern, lactic acid.
ANAEROBIC METABOLISM AND WHY IT CAN KILL
Anaerobic metabolism is the process by which the body produces energy when it lacks sufficient oxygen. To do this you will combust amino acids, fats, oxygen, and carbohydrates. This is what happens during strenuous exercise and is how we lose weight as a result of a workout. Your body is using itself as a gas tank.
The downside is that anaerobic energy production has a by-product; lactic acid. If you’ve ever been on a run and started to feel a pain in your side, that’s lactic acid. When your muscles aren’t getting enough oxygen, they start to burn other things off to get the energy they need, but that causes the lactic acid also produced to build up in the muscle, degrading their performance. If your body is a gas tank, your muscles are the engine, and lactic acid is the exhaust.
The portion of a limb that is being cut off from the blood supply by the TQ is engaging in this process, building up lactic acid continuously. Reintroduction of blood full of L-Lactate to the body can result in a devastating shock, causing lactic acidosis, which leads rather quickly to heart failure. If you’re lucky, that is, as those who survive the cardiac issues will only later become victim to renal failure.
WHEN TO CONVERT
Now that the small biology lesson is done, we can talk about gear.
Easily the most forgotten piece of medical equipment is a watch. It’s how you gather vital signs, create your schedules, and determine when to perform procedures. Plainly, you need to know when you put the original tourniquet on so you know when it is safe to convert it.
Unfortunately, the science of when it is “safe” to convert a tourniquet is still somewhat fuzzy. Civilian medicine has been slow to adopt the tourniquet, and applications in Iraq and Afghanistan rarely require one be worn for long enough to see adverse effects since evacuation operations have become so efficient.
The best information comes from the Journal of Special Operations Medicine, which provides the following guidelines:
- Up to 2 hours after application: Safe to remove TQ
- 2 to 6 hours after application: Likely safe, but the upper limit has not been scientifically determined
- 6+ hours after application: Cannot be removed without advanced cardiac life support available.
To succinctly answer the question “when do you convert a tourniquet?”; it is as soon as you possibly can.
There is no benefit in delaying conversion if the tactical situation permits. With the firefight won, and a moment of relative safety, find some cover and convert away. Just remember, after the 6 hour point, the tourniquet will not be able to be removed without cardiac consequence, and requires the patient to be at a high level care facility with the proper staff.
If you are unsure how long a tourniquet has been in place, do not attempt conversion. A life is not a fair trade for a limb.
Materials needed will be a pressure dressing, packing gauze, tape, and another tourniquet.
- Place your Plus One Tourniquet above the one already in place. “Above” meaning closer to the torso or groin than the other. Leave this one loose, this is a fail-safe. Many tourniquets are only rated for one-time use, this will cover you in case the original tourniquet goes to shit.
- Pack the wound tightly with as much gauze as you can. Pressure is your friend here, try to fill every nook and cranny with gauze as this will promote clotting.
- Apply your pressure dressing over the wound. Ensure it is tight, but not so tight to effectively be another tourniquet.
- Slowly loosen the original tourniquet.
- Apply pressure to the wound as needed.
- Observe the pressure dressing for 3-5 minutes. If you see the wound bleed through your bandages, re-tighten the tourniquet and remove the gauze/pressure dressing to try again in 15 minutes.
- If the wound does not bleed through your dressings, secure your pressure dressing with tape.
- Ensure your original tourniquet is placed 2-4 inches above the wound and left loose. This is to re-tighten if the clot in the wound were to blow for any reason.
- Continue to reassess and make preparations for wound management.
WHEN NOT TO CONVERT
Conversion is almost always needed, but there exists reason to NOT convert. These reasons are as follows:
- It has been over 6 hours since the tourniquet was applied.
- Amputation. Do not convert a completely severed limb.
- You cannot observe the wound. Do not convert if you cannot commit time to staying with the patient and watching for the dressings to bleed through.
EVEN MORE AFTER THE IFAK
That’s it for now. I hope you found this section useful and expanded your frame of care without demanding any skills you didn’t already know with the IFAK equipment you have.
In the next part we will cover something that even combat medics and paramedics often over looks when it comes to trauma; Hypothermia.
Stand by to stand by – Papa Rooster.