Given the recent reports of shooting incidents, it’s good to have an idea of how to deal with a gunshot wound victim. Over 100,000 firearms-related injuries are treated in emergency rooms every year in the U.S.
Of course, in normal times, call Emergency Medical Services and get that person to a modern medical facility. But what about times of trouble when you can’t access modern medicine?
In situations without Rule of Law, you can expect civil unrest leading to cases of ballistic trauma. Rapid action is needed to increase the survivability of these cases. In this article, we’ll discuss how to prevent avoidable deaths due to bullet wounds in austere environments.
Gunshot wounds cause a great deal of damage due mostly to the speed at which the projectile strikes the “target”. For more information on wound ballistics, check out my article: “Basics of Ballistic Trauma”.
THE FIRST THING
In any active shooter situation, the first thing you should do is avoid becoming the next victim. The medic must put their own safety as a priority until the threat has been clearly abolished. If you’re the medical resource for a family or group, you do them a disservice in this situation by not being cautious.
ABCDE VS. CABDE
Once you have established that it is safe to approach the scene, determine the number of victims. If there are multiple casualties, triage as you would in a Mass Casualty Incident (MCI). For a common-sense strategy in these cases, here’s part 1 of my 2-part series on the subject:
With a single victim, the initial assessment usually involves the mnemonic ABCDE:
Airway: Is the airway open? Breathing: Is the victim breathing? Circulation: Is the victim bleeding? Disability: Can the victim feel and move extremities? Can they respond appropriately to questions? Expose: Can you see the full extent of the injury or injuries?
This sequence changes in the actively bleeding gunshot wound to CABDE. In these circumstances, the cause of death is more often hemorrhage, which must be abated quickly. The determination of airway and breathing can often be done simultaneously with bleeding control, as many patients will be conscious and talking.
STOP THE BLEEDING
To stop bleeding:
-Apply direct pressure on the cut or wound with gloves and a cloth or gauze barrier until bleeding stops. Although you may remove loose debris, don’t remove or apply pressure directly to embedded objects, as they may be blocking further bleeding. Pack dressings around the object to keep it in place. If you are on your own for the long-term, you eventually will have to deal with this issue once you have more medical supplies.
-If blood soaks through the barrier, don’t remove it. Put more cloth or gauze on top of it and continue to apply pressure.
-If the wound is on the arm or leg, raise the limb above the heart to help slow bleeding. Many experts say to avoid this if the actively bleeding wound is in the torso, which might increase bleeding (a conundrum if the patient is in shock).
-Pressure points may be compressed to decrease bleeding. Pressure points are areas where compression of a large blood vessel near the surface above the wound will slow down hemorrhage below. Specific pressure points correspond to areas of bleeding injury. This method is not of much use unless the medic is aware of the “map”, however.
-Inspect the patient for exit and other wounds. These may be in unusual locations, as a bullet may deviate from a straight path when it strikes tissue. An exit wound is often larger than the entry wound. EMT shears/bandage scissors are helpful to cut away clothing without excessive movement by the victim.
-A compression dressing such as the Israeli Battle Dressing (called “The Emergency Bandage” in the U.S.) may be needed to stop heavy bleeding. This type of dressing is meant to provide constant pressure on a wound.
“Israeli Battle Dressing”
-In some cases, the use of a tourniquet may clearly be the first action that must be taken, although many sources recommend it only as a last resort. Tourniquets should be placed 2 inches above the level of the bleeding wound but below the shoulder or buttock. Avoid joint areas. Tighten until the pulse below the wound is absent. If one tourniquet fails to stop the bleeding, use a second one above the first. Mark the time it was placed on the patient’s forehead for later reference. In a future article, we’ll discuss tourniquets and their use in much more detail.
-Hemostatic agents such as Celox, Quik-Clot, or Chitogauze may be useful adjuncts to stop bleeding quickly in active hemorrhages. These dressings are impregnated with substances that stop bleeding. Although they may be difficult to clean out later, they may save a life.
Celox hemostatic dressing
-Don’t try to remove the bullet. It is likely deeply embedded and/or fragmented. Searching for it may cause more bleeding.
-Cover the patient with a blanket if available to stop the loss of body heat, a common consequence of shock due to gunshot wounds.
-Immobilizing an extremity wound may prevent a recurrence of bleeding.
-Expect dirt, clothes, and other debris to have been pushed into the wound by the bullet. In other words, these wounds are dirty. Antibiotics will likely be necessary to prevent infection.
Due to the extreme damage that can occur in a gunshot injury, your off-grid success using the above strategies will be variable. It should be noted, for example, that some bleeding wounds will respond to compression and some will not. Wounds in the torso (chest and abdomen) are unlikely to stop bleeding internally with simple compression. Surgery is usually required, which means that you can expect high death rates with these types of injuries in survival settings. During the Civil War, chest and abdominal wounds carried deaths rates of 60-70% or more.
The location of the gunshot wound may require adjustment of some of the above recommendations. In future articles, we’ll discuss specifics regarding different sites of injury, needed medical supplies, how blood clots, and much more.