The Medic’s First Priority

The World Health Organization (WHO) reports that, In the Democratic Republic of Congo, rebels have killed four medical workers in the eastern part of the country.

The deaths occurred when armed men entered a U.N. base in Biakato and started shooting. According to one official, warnings had been given previously to health workers in the area to leave or “face the worst”.

Those fighting the Ebola outbreak fear that the incident will cause an exodus of caregivers from the area, where Ebola cases had been waning lately. A total of more than 2200 fatalities have been documented in what had been considered the second-worst Ebola outbreak in history.

Approximately 300 attacks on healthcare providers have occurred in 2019. Health workers have (so far) continued to provide care despite the risks of contagion and hostile locals.

Armed rebels aren’t the only threat: In response to fatal militia attacks on civilians, local residents recently stormed a UN peacekeeper’s camp, putting the blame on their presence in the area. Ebola teams were subsequently told not to report to work until the situation settled.

ASIDE: The Congo is also in the midst of the world’s largest measles epidemic, which has killed at least 5000, almost all children, so far.

THE MEDIC IN LONG-TERM SURVIVAL SCENARIOS

The violence experienced by health care workers in Congo may be extrapolated to long-term survival scenarios. Certainly, civil unrest and other hostile encounters may put a group’s medic in harm’s way. In situations where the rule of law is non-existent, caregivers must determine their priorities.

You might think that the medic’s first priority is to care for the sick and injured. In most situations, this is a reasonable assumption. Unfortunately, not all medical care will be rendered in peaceful circumstances. When you’re under the threat of hostile fire, the priority shifts to your own self-preservation.

Simply put, you do a disservice to your survival community by becoming the next casualty. You can expect to be a prize target for hostile forces if you wear any insignia denoting medical responsibilities. Eliminating the medics is a great way to decrease the effectiveness of the group and deliver a devastating hit to morale. 

THREE PHASES OF COMBAT CASUALTY CARE

Doing the right thing at the right time is the cornerstone of tactical combat casualty care (TCCC).  This does not always mean good medicine; in an unsafe environment, good medicine might be bad tactics; indeed, it can get you killed. The medic must assess the situation before running into the line of fire.

TCCC encompasses all appropriate field care rendered to casualties in the field from the point of injury until they are out of the danger zone and delivered to the nearest medical facility. There are three phases:

• Care Under Fire: In the presence of others with hostile intentions, the medic must remained engaged and determine the risks. An important goal in this case is to abolish all threats, and this means helping to provide suppressive fire if needed.  Yes, the medic should always be armed. The best medical care when under fire is eliminating the enemy. If you can’t, at least keep their heads down and weapons silent. If the casualty can be reached, get them to cover and stop major bleeding by using a tourniquet as a first course of action.
• Tactical Field Care: Still in the area but away from immediate danger, the medic must employ basic and advanced life support measures. During this phase, the medic would establish airways, seal open chest wounds, apply wound dressings, splint fractures, and work to prevent hypothermia from shock. If access to intravenous lines is available, they would be placed here.
• TACEVAC: At this point, the medic focuses on further stabilization and, then, transport to the next highest medical resource. In normal times, this would be a field hospital or trauma unit. Off the grid, it’s wherever the bulk of your medical supplies are. In this more controlled environment, the medic can reassess bleeding wounds, tourniquet placement/conversion, provide airway management such as chest tubes if possible, treat pain, and consider antibiotic therapy if appropriate.

THOUGHTS FOR THE SURVIVAL MEDIC

The medic may find 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 shooting.  As well, it’s foolhardy to use a head lamp at night to treat the wounded; it might as well be a target bull’s-eye.

When under fire, therefore, I believe that your priorities should be:

1) Abolish or suppress the threat.

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

3) If exposed, get the casualty and yourself to reasonable cover as soon as possible.

4) Use your tourniquet along with direct pressure and other hemostatic (blood-clotting) methods to stop heavy bleeding. When under fire, apply it “high and tight” and don’t waste precious time cutting through clothing.

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

Notice I don’t mention airway management or cervical spine immobilization while under fire. In a safe environment, these are two basic steps in evaluation, care, and transport of trauma victims. Stopping the hemorrhage, however, will be the most likely way you’ll save a life in this scenario.  You don’t have the time to do much else.  That part happens when you aren’t in the hot zone .

The importance of cross-training can’t be overestimated in these situations. Everyone in your group should carry and know how to apply a tourniquet and other hemorrhage control items correctly to themselves and others.  

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 the rest of your people know about how to deal with medical issues, the higher the chances to survive tough times.

One last thought I’d like to share: I have the highest respect for the military medic, who has a tough job in the best of circumstances. If you’re one, you’ll never have to prove your courage and fortitude in any other way. Just be sure to have a plan for scenarios where you might be the end of the line when it comes to definitive treatment and long-term care.

Joe Alton MD

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