“I am dying.”

This was the tweet posted by Oleysa Zhukovskaya, a 21 year old woman who volunteered to function as a medic during the recent Ukrainian protests. Police snipers were targeting medics (marked with red crosses) and journalists; Zhukovskaya was struck in the neck by a bullet.

Seeing this drama unfold, I considered long term survival scenarios in which civil unrest and other events may put the group medic in harm’s way. This may involve situations where the medic is with his/her group in foraging operations, or simply at “base camp” when hostile forces arrive, as in the Ukrainian example mentioned above.

In Kiev, the young woman might have thought her red cross identified her as a “non-combatant” and made her immune to enemy fire.  Despite the Geneva Convention, this probably could not be further from the truth: Eliminating the medics is a great way to decrease the effectiveness of the group and could be a devastating hit to morale.  So a basic piece of advice is to avoid wearing a big white armband with a red cross; US military medics today wear a much less noticeable insignia.

Doing the right thing at the right time is the cornerstone of tactical combat casualty care (TCCC).  This is different from what you might consider to be the practice of good medicine. In an unsafe environment, good medicine could be bad tactics, and that could get people killed.

This poses the question:  Should medics be armed?  I say “Durn tootin’ they should”.  An important goal in this case is to abolish all threats, and this means helping to provide suppressive fire if needed.  The best medical care when under fire is eliminating the enemy, or at least keeping their heads down and weapons silent.

This tactic is hard for the medic to swallow, as they will want to attend to wounded members first.  Without dealing with the threat, however, they are likely to become the next casualty if they run into the line of fire. History shows us that this was a common way for the medic to meet his demise, sometimes on the way to evaluate casualties that were already beyond help.

A second issue for the medic is that many of the tools used to evaluate a victim will be useless in a firefight.  Forget trying to listen to a casualty with a stethoscope if there is gunfire.  As well, it’s foolhardy to use a head lamp at night to treat the wounded, as it might as well be a target bull’s-eye.

When under fire, therefore, your priorities should be:

1) Abolish or suppress the threat.

2) Avoid exposure to enemy fire while attempting to reach a casualty.

3) Get the casualty and yourself to reasonable cover.

4) Use your tourniquet along with direct pressure and other hemostatic (blood-clotting) methods to stop heavy bleeding when appropriate.

5) Figure out a way to transport your victim and yourself away from hostile forces.

Notice I don’t mention airway management or cervical spine immobilization, two basic steps in evaluation, care, and transport of victims of trauma in a safe environment.  This is good medicine, but control of hemorrhage will be the most likely way you’ll save a life in this scenario.  You don’t have the luxury of time to do much else.  That part happens when all is clear, and is called tactical field care.  We’ll discuss what to do next in future articles.

Something that was clear to me in these settings was the importance of cross-training.  Everyone in your group should know how to apply a tourniquet correctly to themselves and others, as well as other basic hemorrhage control strategies.  If the medic is the wounded party, the ability to give concise instructions to others under stress could save a life (yours!). If you are the medically responsible member of your group, think about what you would tell other group members to do if you were bleeding, broke a bone, were sick, etc.  The more people that know how to deal with medical issues, the higher the chances to succeed, even if everything else fails.

By the way:  Our Ukrainian medic was transported to the hospital, and survived.

I have the highest respect for the combat medic, who has a tough job in the best of circumstances.  To see what goes into becoming a Special Ops Combat Medic, see this excellent first-person account from someone who went through the training:

https://hitthewoodline.com/militaria/2013/7/24/inside-the-special-operations-combat-medic-course

Joe Alton, M.D., aka Dr. Bones