If you carry a firearm as part of your job, or are a civilian who carries for personal protection, it is imperative that you know what to do to save yourself or others from dying from a survivable gunshot wound. That means knowing more than just basic first aid. The following information is also useful for anyone who is one scene in the aftermath of an active shooter attack.
We are fortunate that we can capitalize on U.S. Military research and development advances in the treatment of gunshot wounds. But before addressing advanced first aid treatment for gunshot wounds, it is recommended that you learn basic first aid. A First Responder first aid course will familiarize you with the variety of first aid equipment used to address major life-threatening injuries, especially those caused by firearms.
Legal Aspects of First Aid
Two key elements of “Good Samaritan” law that dictate what you can do when rendering first aid. The first is based on the condition of the victim. Specifically, is the victim conscious or unconscious? If the victim is conscious, you need their consent to help them. If the victim is unconscious, there is implied consent that you can help them. The second factor in avoiding litigation is to avoid “wanton disregard for the health and safety of the victim.” Use common sense and avoid any questionable actions such as using a dirty shop rag to bandage a wound.
In preparing a response to any emergency be it fire, natural disaster, or man-made, you should have an Emergency Response Plan (ERP). Ideally, if you carry a firearm as part of your job, your ERP should be in writing. In any first aid situation that may involve a firearm, the “ACR” acronym provides you with a basic plan for addressing the situation:
A (Arrive, Assess, Approach)
C (Confirm, Call, Control)
Arrive: at the scene and locate the victim(s)
Assess: Is the scene safe, what is the threat level. Use cover and concealment tactics and know where the exits are located.
Approach: Slowly approach the victim. Are they armed? Do you move the victim or aid in place? If you move them, you must know how to use established methods to prevent further injury. For example, drag, wheelbarrow, two-person carry, assisted walking, to name a few.
Confirm: if there is an injury, you must call EMS; this is required by law! Make the call yourself or direct bystanders to do it, then confirm it is done. Maintain your calm and reassure the victim.
Control the Scene: Get consent from the victim if they are conscious. Decide if you will render aid or if you can elicit the help of bystanders. If you render aid, someone else may have to direct the rescue or you may have to do both. If others render aid, assume control of the scene and direct the rescue. Pay specific attention to assigning someone to call EMS and ensure someone will go meet EMS when they arrive and bring them to the victim. If waiting for transport is not viable, you may have to use bystanders to get a vehicle to transport the victim to proper medical care.
Render Aid: Before rendering aid, don your protective equipment (gloves, safety goggles, etc.). This can be done while you are ensuring scene safety and asking for consent from a conscious victim.
Basics of Ballistic Wounds
To treat a gunshot wound it is beneficial to understand what damage bullets do to human tissue. The extent of injury from a bullet is due to:
• The mechanical shredding and crushing of tissue by the bullet as it perforates the tissue.
• Shearing, compression, and stretching injuries to the tissue due to temporary cavity formation.
• Secondary injuries due to breakup of the bullet.
The expanding walls of the temporary cavity can cause severe damage. There is compression, stretching, and shearing of the displaced tissue. Injuries to blood vessels, nerves, or organs not struck by the bullet, and at a distance from the path, can occur, as can bone fractures, (rarely). Maximum expansion of the cavity does not occur until after the bullet has passed through the target.
Handgun bullets produce a direct path of destruction with less damage to surrounding tissues (small temporary cavity) than does a rifle bullet. Centerfire rifle bullets cause destruction via crushed and shredded tissue generated by the bullet perforating tissue, the effects of the temporary cavity on tissue adjacent to the bullet path (shearing, compression, and stretching) and secondary injuries due to fragmentation of the bullet.
Causes of Death via Ballistic Wounds
Discounting immediately fatal wounds (head, heart, and other major organ damage), according to research, 66% of preventable deaths were due to extremity hemorrhage, 30% due to complications from a torso wound (sucking chest wound/tension pneumothorax), and 3% involving airway issues.
With a basic understanding of how bullets damage humans and the most likely causes of preventable death from gunshot wounds, how do you treat these injuries? Specifically, what first aid is useful to treat these types of wounds? Do you know how to administer appropriate first aid? If you KNOW what to do, do you regularly carry the necessary tools and supplies to perform the treatment?
Tactical Combat Casualty Care (TCCC)
Tactical Combat Casualty Care – “Tee Triple See” (TCCC) is the medical training that U.S. troops are currently taught to save lives on the battlefield. It is the result of collaboration between U.S. Special Operations Command, trauma doctors, and emergency medical personnel. TCCC incorporates procedures proven to save lives and reduce the number of preventable deaths on the battlefield. The U.S. Army 75th Ranger Regiment trained all its troops and doctors in TCCC. This resulted in a drop of preventable battlefield deaths from 24%, the average for U.S. combat troops, to 3%. These procedures are not to necessarily save someone’s life, but to keep them alive long enough to receive hospital level care. TCCC is now being adopted by law enforcement to designate immediate medical care given to trauma victims of violence, specifically, from gunshot wounds.
The acronym of M.A.R.C.H.(E.) describes the TCCC methodology. It directly addresses the life-threatening issues a person will face when treating a gunshot wound. The acronym is used to remember the order of treatment, descending in order of importance.
• Massive Hemorrhage
• (Everything Else/Evacuate)
Massive Hemorrhage – Bleeding
In tactical medicine, the number one killer is massive hemorrhage, followed by a blocked airway. Often, before emergency responders arrive on scene, a victim will die from massive hemorrhage – in as little as 1-3 minutes. Major blood vessel penetration or a complete or partial amputation causes massive hemorrhage. Bleeding that is bright red, squirting, or heavy, is considered massive hemorrhage and needs to be treated immediately. A major bleeder can kill someone in minutes; therefore, prompt treatment is essential.
Massive Hemorrhage Treatment
The two main treatments for massive hemorrhage are wound packing and tourniquets. The location of the wound directly influences which of these methods will be most effective and will determine your immediate action:
Extremities: For wounds to the extremities use direct pressure, wound packing, and tourniquets to restrict severe bleeding.
Junctional: For wounds in junctional areas of the body such as the neck, the groin, shoulders, and armpits, use direct pressure and wound packing.
Torso: For wounds in the torso, from hip to shoulder, use wound packing and attempt to seal the area
5-Point Checklist For Managing Massive Hemorrhage
One: Body or Wound Positioning: Attempt to elevate the bleeding injury above the heart. Be conscious of possible spine or neck injury.
Two: Direct Wound Pressure: Compress the bleeding vessel against the bone or ground. This requires dedicated and very hard pressure covering a large surface area using your palm, not your fingertips. Pressure must be maintained to prevent recurrence of blood loss. The most effective method is to use straight arms and shoulders directly over the wound and apply full body weight to compress an arterial injury. Do not remove the pressure to reassess!
Three: Junctional Wound Packing: To treat major bleeding to a junctional wound to the neck, the groin, shoulders, and armpits, use gauze or hemostatic agents. The principle behind wound packing is that it puts internal direct pressure close to or at the bleeding vessels (proximally or closer to the heart) by pressing the blood vessel against a bone.
If the wound is deep, or in the victim’s trunk, place gauze or other dressing as deep into the wound as possible. Pack the entire wound with gauze, ideally placing it towards the victim’s head as you pack. This will ensure that the immediate blood flow stops and will maximize the clotting effect. Even if the dressing soaks through with blood, leave it in place. If removed, it will remove the clot you are trying to form. Once the entire cavity is packed, wrap it with another bandage to secure it in place.
When applied properly, the pressure from the packing will slow the bleeding enough for platelets to clot, and seal off the blood vessel from further blood loss. Use packing in combination with direct wound pressure and wound positioning. While more time intensive than applying a tourniquet, wound packing can be just as effective at stopping bleeding.
Hemostatic agents such as Celox, QuikClot, and Hemcon can be combined with wound packing and are designed to promote rapid blood coagulation in traumatic arterial wounds. Hemostatic agents foster a much more robust and durable clot, which is helpful when the victim is moved. Hemostatic gauze products are now widely available and approved for training and use in some areas.
Four: Pressure/Compression Bandage: This type of bandage provides direct wound pressure and is used to dress an injury prior to victim transport or movement. It is used in combination with direct wound pressure. A common example of a pressure bandage is the “Israeli” Compression Bandage.”
Five: Tourniquet Application: The tourniquet is an essential tool and its application is the preferred method for treating potentially lethal massive hemorrhaging from compressible extremities: arms and legs. A tourniquet compresses the limb and vessels against the bone above the wound and stops the flow of blood at the wound site. Applied properly, a tourniquet is a fast, cheap, and extremely effective way to stop bleeding. There are many different types of tourniquets but they all work roughly the same.
Apply a tourniquet as “high and as tight” as possible, 4 – 6 inches above the wound, directly on the skin if possible, and tighten it until the bleeding stops. If placed too low on the limb near the wound, the pressure generated on the blood vessel will not be great enough to stop the bleeding. Likewise, if it applied too loosely, the tourniquet will not be effective. If bleeding continues, a second tourniquet may be required – leaving the first in place and adding the second one between the first tourniquet and the body.
A number of deaths have been attributed to tourniquets being applied too loosely, where if applied properly, the bleeding could have been controlled and the victim saved. NOTE – properly applied, a tourniquet is VERY uncomfortable. Victims will plead and beg, or even try to loosen the tourniquet themselves, but under no circumstance should a tourniquet be removed by anyone other than a trained medical professional. An example of a common tourniquet is the C.A.T. (Combat Application Tourniquet).
Effectiveness: You can judge the effectiveness of the tourniquet if it is obvious that bleeding has slowed or stopped, and it if there is an absence of a pulse in the distal side of the limb – the part of a limb away from the heart and the tourniquet.
General Rule: Add techniques and actions, but never undo what you have done. This means do not remove direct pressure, bandages, or tourniquets – but you can add to them.
The second leading cause of death from a gunshot wound is a blocked or restricted airway. If the victim cannot breathe, they will expire in roughly four minutes. If a victim can talk, cry, laugh, or scream, they have a clear airway. If unconscious, a victim may choke on their tongue as it may relax and, being a large muscle, may fall back and block the esophagus.
Besides the standard head tilt, chin lift method to open an airway, the standard TCCC procedure to prevent a blocked airway is to use an easy procedure called a nasopharyngeal (NPA) or “nose hose.”
This flexible rubber hose is inserted into a victim’s nose to open the airway from the nostril to the back of the throat.
When inserting a nose hose, push the hose straight back towards the spine, not up towards the bridge of the nose, as the nasal cavity goes straight back. After inserting a nose hose, make sure to look inside the victim’s mouth for any obvious obstructions but take care not to place your fingers inside the victim’s mouth, as the victim can seize and bite down without warning.
Lastly, if the situation applies, and there are no cervical spine complications, consider rolling the victim onto his or her side, as this will help keep the airway clear of any fluids, such as vomit or blood, as well as the victim’s own tongue.
After addressing massive hemorrhage and airway issues check the victim’s respiration. Remove outer clothing and look for an equal rise and fall of the chest, listen for breathing, and feel the chest rise. The risk to respiration is a pneumothorax, a penetration to the chest cavity that lets air into the pleural space – the area surrounded by the rib cage that protects the lungs and heart. This air bubble puts pressure on the lungs and heart, a condition that can be fatal if left untreated. Pneumothorax starts with shortness of breath, labored breathing, and can lead to the victim feeling an impending sense of doom, unconsciousness, and death.
If there is any wound to the torso, the area from the belly button to the neck and 360 degrees around the body, immediately seal the torso wound by placing your hand over it and then sealing the hole, preferably with a medical chest seal – occlusion dressing. In a pinch, duct tape and any airtight wrapper will seal the wound. If a gunshot wound is suspected, check very carefully for an exit wound, and if evident, seal that wound also to prevent air from entering the chest cavity.
The TCCC procedure addressing circulation begins with checking the victim for shock: the inability of the body to transfer blood to tissue. In the case of traumatic injury, this is usually due to blood loss. Sensing loss of blood, the body begins to shut off blood flow to the outer, less essential areas.
The easiest and quickest ways to check for shock is to check the victim’s radial (wrist) pulse. If there is a radial pulse, the body is still pushing blood to the hands. If no radial pulse is present, it is an indicator the body is using blood to maintain vital functions and is no longer pushing blood to the less essential outer extremities. The body is going into shock.
To prevent shock, immediate treatment of massive hemorrhage is critical, as it reduces the amount of blood loss. Additionally, elevate their feet, unless there is any indication that the victim has a spinal injury, in which case you DO NOT want to elevate their feet as this could paralyze them. Lastly, get fluids back into the victim as quickly as possible to prevent shock.
Hypothermia can be an issue for wounded victims, as any blood loss or injury can reduce the body’s ability to retain heat. Even in warm climates, a victim can succumb to hypothermia. To prevent this, after the victim is screened using the M.A.R.C.H. protocol, ensure that any clothes are put back on, and the victim is covered with a space blanket, wool blanket, or sleeping bag.
Head injuries are a serious concern. There may be little you can do for the victim, but it is important to relay any information regarding signs of head injury to medical personnel. The signs and symptoms of brain injury include an altered mental state, “raccoon eye” shaped bruises around the eyes, clearish yellow fluid leaking from the ears, mismatched pupil size, and any bumps or deformation in the skull. Check the victim for any of these signs.
(E) Everything Else/Evacuate
After the M.A.R.C.H. sequence has been completed, move on to everything else. There may be other injuries, while not life threatening in minutes, that are still very important. Any wound that does not strike a major blood vessel or organ is not immediately life threatening but can still look scary. Injuries like this include cuts or wounds on the outside of the body, such as the forearms, outer legs, buttocks, and shoulders. Since the major blood vessels are located on the inside of the body and protected by bone and muscle, wounds to the outer parts of the body can be dealt with last, usually with a simple pressure dressing/bandage.
Build an IFAK
Not all first aid kits have the necessary equipment to support the TCCC system. However, it is relatively easy and inexpensive to build your own Individual First Aid Kit (IFAK). Your IFAK can fit into a pack as small as 3”x 5”x 8” and can easily be carried on your belt, in your briefcase, or backpack. Ideally, you should stage IFAKs in your vehicle, your home, and at your workplace. A typical IFAK should contain the following items:
• At least one (1) Tourniquet (preferably a C.A.T)
• Gauze/Fluffy Dressing
• Space Blanket
• Chest Seal/Occlusion Dressing
• Nasopharyngeal tube with lubricant
• Face Shield
• Surgical tape
• Compression Bandage (Israeli)
Adding a hemostatic agent such as Quickclot Combat Gauze will increase the cost of your IFAK and require replacement at least every two years.
Everyone who carries a firearm should take responsibility for their lives as well as the lives of victims and learn to address the treatment of survivable gunshot wounds by utilizing the TCCC/M.A.R.C.H. system. Application of the TCCC system principles is useful in non-firearms related emergencies too, as it can be applied to traumatic injuries resulting from vehicle accidents or bomb attacks, thus giving the wounded a chance to survive until professional medical responders arrive. It is essential to practice the actual MARCH sequence so you will remember what to do if you are faced with a life-threatening gunshot or other massive bleeding wound.
The content of this article is intended to provide a general guide to the subject matter. Medical and legal specialist advice should be sought about your specific circumstances.
PSC member Thomas (Tom) Pecora has over 27 years of experience in crisis management, personnel and physical security, and counter-terrorism. He retired as a CIA Senior Security Manager after 24 years of service including managing large complex security programs and operations in Africa, Latin America, Southeast Asia, Europe, the Middle East and the war zones. Today he is the Director of Pecora Consulting Services and provides consulting services in security vulnerability and threat assessments in Asia and the US, personal safety and crime prevention/avoidance, and executive protection guidance and skills training. Read his entire bio in the PSC Member Directory. Contact him at firstname.lastname@example.org
Introduction to Tactical Combat Casualty Care – Hugh James Latimer, SurvivalBlog.com, August 22, 2014
Operational Emergency Medical Skills Course Manual, LTC (Ret) J. Hagmann, M.D., 2004
Tactical Combat Casualty Care, Committee on Tactical Combat Casualty Care, Government Printing Agency, Feb 2003
Tactical Combat Casualty Care in Special Operations, CPT Frank Butler, Jr., MC, USN; LTC John Hagmann, MC, USA; ENS George Butler, MC, USN, Military Medicine, Vol. 161, Supp 1, 1996
Pistol courtesy of Phiseksit at FreeDigitalPhotos.net
Bandages courtesy of franky242 at FreeDigitalPhotos.net
Compression bandage courtesy of Sgt Cesar Leon/DVIDS
“Nose hose” courtesy of Sgt Cesar Leon/DVIDS
Tourniquet courtesy of INDAM, Wikimedia.org
Fisrt Aid Kit courtesty of FreeImages.com/Michael Fares