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Mass Casualty Incident!!

Mass Casualty Incident!!

Responding to a Mass Casualty Incident

Awhile back, we had the massive explosion in Lebanon. More recently, we had the horrific explosion in Kabul that claimed the lives of 13 Americans and over 100 Afghans. 

The first few moments after the explosion are surreal. You don't necessarily know exactly what happened, but you know it's not good. Your brain is in a temporary fog and having difficulty understanding the magnitude of what you witnessed. Your ears are ringing. You check yourself to see if you're injured, and then know you need to help others. Casualties are everywhere. It's initially calm, but then people start screaming for help.  Your brain is having a million thoughts a second trying to assess, plan, process and help all at once. Everyone seems to be moving around, but no one is quite sure how to help. These are the realities of the moments after an IED blast. We know. We've been there before. This post will hopefully help those who have never experienced an incident like this gain a fundamental understanding of what to do should they encounter one (God forbid). 

We tend to think of Mass Casualty Incidents (MCI) as being due mainly to crazed shooters in the civilian sector and IED’s in the military sectors, and you'd be mostly correct. However, MCIs can also occur for a number of reasons, such as earthquakes, tornados, car accidents, and yes, industrial accidents.

The rules for military MCI/CCP’s and civilian CCP’s are inherently different, yet they share many of the same principles of care. Staying safe, rapid evaluation and prioritization of patients, and subsequent stabilization and evacuation.

This post is to help expand the understanding of EMS and First Responders, those with medical knowledge who are witness to MCI, and military medics who need refreshers on helpful tips and techniques.

What makes an MCI an MCI? By military definition, an MCI is when you have more casualties than you do medical resources to support their care.

In a civilian setting, this can also mean a resource constrained environment due to time, availability of services, or lack of nearby medical personnel.

A perfect example of this recently is the explosion in Kabul. The hospitals and EMS in the city were immediately overwhelmed, and hundreds of casualties wandered aimlessly seeking care. 

Rarely will a solitary medic/EMS response team have enough supplies to adequately care for large numbers of wounded simultaneously. We know that even a small delay in resources can have a major impact on the immediate need for care. Therefore, prioritization's must be made.

Step 1: Size the Scene Up

- Is what caused the incident under control? Are you at risk of becoming a casualty yourself? Taking the time to read this and wanting to help means you aren’t a coward. Scene Size Up means you being smart and taking a tactical pause to assess the situation to ensure you do not become another casualty before you’re able to help.

- Begin to assess what type of resources you’ll need. For example, in an explosion may see lots of amputations, burn injuries, head injuries, cuts from shrapnel etc., a shooting—puncture wounds, and in a car accident—blunt force trauma. Thinking about what injuries will most likely accompany an event will help you to immediately plan your response.

- Identify any onlookers who have medical training and /or are willing to help. Remember, people are more willing to help when directed. Saying “I need you to help me get this patient moved over here” is more effective than saying “who will help me?”.

If you are the bystander with no medical knowledge, take direction. Use available resources, and be proactive about reporting back to the medic with what you see. 

Step 2:  Identify a Casualty Collection Point (CCP)

- You’ve taken a second to recognize there will be multiple casualties requiring medical care. Rather than continuously running between each casualty over the entire casualty scene, it is necessary to get them all in the same area to render effective care. Identify a casualty collection point (CCP), preferably close to the patients but out of harm’s way. Must be accessible to emergency vehicles to begin accepting and transporting patients when they arrive. 


Step 3: Begin Initial Triage of Patients

  - A good way to begin is to yell out “If you are wounded and can walk, walk to the sound of my voice”. Those who may be less seriously injured and still conscious can identify themselves and begin assembling towards you. This will reduce your need to visit every patient and assess.

- Begin a systematic but expedient walk-through of patients. Identify injuries that need to be handled immediately, such as massive bleeding.

- Once you have identified a patient who needs immediate intervention, direct others to apply a tourniquet if they know how. If no one else knows how, apply a tourniquet, direct someone to hold pressure, or pack the wound yourself as quickly as possible. Have someone else hold packing in place once complete and move on to next patient. Remember, in this step, you are doing only immediate and life-threatening interventions only and moving on to more patients.

- Continue identifying all patients by order of seriousness of injury and have them moved to CCP and arranged accordingly.

Step 4: Take charge of Casualty Collection Point

The CCP is meant to assemble, continue triaging, stabilize and subsequently evacuate your casualties.

How you set up your CCP matters.

1) Organize patients by severity of wounds. Keep patients who will need greater attention together allows more rapid assessment, treatment and attention.  Try and keep the more severely wounded patients closest to where you expect them to be picked up by transport.

2) Economy of movement means being able to treat, direct treatment and move between patients as quickly and efficiently as possible. We recommend setting up your patients in the following ways to maximize efficiency. The lead medic establishing a presence in the center of the wounded allows for rapid evaluation and easy to direct patient care. 

Color BLACK: Expectant—Do not waste supplies on those who are dead or who would take up a sizable amount of resources with a small amount of survival.

-- Examples of Expectant injuries include: Exposed brain matter, agonal respirations, severe polytrauma.

-- A good rule of thumb is to separate the dead and expectant from the rest of those in your CCP, both for the sake of the living patients and to minimize confusion in a chaotic situation.  

Step 5: Begin systematically treating patients

As the lead medic, you will be responsible for directing care. As you move from patient to patient, assess rapidly through the MARCH algorithm.

1) Is the massive bleeding under control?

2) Is their airway open and patent?

3) Are their breathing/respirations adequate?

4) Is perfusion/circulation adequate?

5) Is this patient covered properly to prevent hypothermia?

Above diagram courtesy of @the_resusitationist
 - What we found to be effective was assigning a helper when available to each patient. The lead medic would rapidly assess MARCH for each patient. The helper would then be given instructions like “I need you to place your hand here and hold pressure, and don’t move until I get back” or “Keep the patient covered, and every 2 minutes I want you to count their respirations and pulse”. 

- If you were to work through the full MARCH algorithm yourself on each patient, it would delay vital assessments on other patients. Quickly understand what is happening to each patient, direct a helper to fix the issue, and move onto the next patient.

- We cannot stress this enough; In a mass casualty incident where you are responsible for multiple patients, your job is to DIRECT CARE as much as possible. You can direct others to place/check tourniquets, hold pressure on wounds, position people, cover them, etc.

- In a resource constrained environment, placing a hand on a chest wound may have to suffice instead of a chest seal. Putting pressure on a heavy bleeder with a shirt may have to take the place of a proper bandage. You as the medic know what supplies you have and which ones you do not. You must be smart about how and when you use them.

- If complicated procedures must take place, such as cricothyroidotomy, the medic would still be responsible for that.

Step 6: Continuously work to upgrade the status of your patients.

You’ve gone through your initial assessments. Starting with the most severely wounded, begin using what limited resources you have to upgrade when possible. Have an idea of who you want EMS or higher-level medical authorities to pick up first, and be prepared to give them proper vitals, treatments etc. when they arrive.

Final Thoughts

MCI’s and establishment of CCP’s are rare, but must be practiced. You can expect chaos, confusion, and a high-pressure environment. Don’t let the first time you experience it be a real-life event. 

If you are a medic, LEO, First Responder, etc. Please work an MCI, CCP etc. into your training. Even practicing it one time can have a significant impact on your ability to understand what is expected of you. It will also demonstrate how rapidly supplies are used, and can help you better assess and treat patients with alternative methods.

If you have experienced a Mass Casualty Incident, and want to share some feedback, please do so in the comments to continue the learning points!

If you want to help, but aren’t sure how, please check out our First on Scene Guides HERE. It will help walk you through the SMARCH algorithm of care, as well as how and where to place tourniquets, how to pack wounds, where to place chest seals, how to perform CPR, and more!

For military medics, we have an excellent guide for you HERE.

If you have or want to purchase a medical kit, but aren’t entirely sure how to use the contents within it, we have you covered with our Medical Kit Quick Reference Guide HERE

For all other medics…we have a full assortment of guides for you as well!

Visit us at !!!


The Misadventures of an 18D

The Misadventures of an 18D

The misadventures of an 18D across the world.

It’s easy to forget that between the cool guy pics and polished image of many social media accounts, we’re all just normal humans. Nobody is perfect, least of all the 18D medics here at Ready Warrior LLC. We’ve done and experienced some things that will make you probably wonder how we ever made it to a team in the first place, let alone stayed on one. So, let’s hit just some of the lowlights of times where we had some misadventures or just sucked at life. What follows is a collection of short stories that highlight the stuff that never makes it into the books or media.

The Rooster that had to Die

On our first trip to the Philippines, our team was assigned a training mission in a small town on the island of Mindanao. When we arrived, it was exactly what you’d imagine a jungle camp to look like. Bamboo hunts, thatched roofs, and minimal security. If you’ve ever been to the Philippines, you know they love cock fighting (roosters—not…never mind). The camp had dozens and dozens of roosters. Some were roaming free, but the prized ones they used for cockfighting and guard duty were kept in small basket cages outside the soldier’s quarters. Okay, we thought, whatever works for them.

Only problem was…unlike in cartoons where a rooster crows a few times early in the morning to wake you up and then shuts up, these annoying bastards never stopped. Ever. Cockledoodledoo all !&#&@* night. What was worse, someone in the camp kept their rooster directly outside my window. After two nights of horrible sleep, I asked the soldier if he would mind moving his rooster somewhere else. He just laughed and replied ‘No’. Earplugs didn’t work, and I wasn’t about to wear Peltors to bed.

By night 5 I was at my wits end. We were working 16hr days, and the lack of sleep was getting to me. At approximately 3am on the 5th night, I snapped. I took my knife out, walked outside, and shanked that stupid rooster to death. I walked back into the team hut and saw my Team Sgt, who shared the room next to me, staring at me from outside his door. I still had the knife still out and had blood and feathers on my hand. I was one of the newer guys on the team, and I was worried that he was going to send me back home the next morning for this stupid act. He simply replied “If you hadn’t done it, I would have” and went back to his room.

 The next morning, the soldier who owned the rooster was PISSED. I thought we were going to get into a rumble, but after some back and forth, I offered him $80 to replace the rooster, under the condition that he no longer keep the rooster anywhere near our hut. He was more than happy to take that deal. I finally got a decent night sleep for the first time that night..but that didn’t last long, because I got sick…really sick. To be continued in….

The Balut that got me

Not long after the rooster episode, myself and a teammate were invited to try an Asian delicacy called Balut. Some of you may know what that is already, and have already gagged a little. For those of you who do not, it is a duck egg. Let me be more specific. It is a duck egg, that has been fertilized, and the baby duck is 14-21 days gestation when its development is stopped and it’s sold. You buy the duck egg, poke a hole in the top of the egg, dunk it in a vat of vinegar, and then suck the partially developed duck and yolk down. Depending on the stage of development, a feather may tickle your throat on the way down. See below for an example:

Surprisingly enough, I found them to be delicious in a weird, scrambled egg type way. I ended up eating two of them during that short break in training we had, each time dunking them in the pitcher of vinegar and spices with everyone else. By now you're probably seeing where I went wrong. 

It was later that night the trouble started. I shot out of bed like a bolt of lightning at 1am with huge stomach aches. Yep-bathroom time. Then again at 2am, 3am, 3:30am, 3:45am. After 5 nights of barely sleeping because of a now-dead rooster, I was awaked again because my insides had decided to set themselves on fire. Without exaggeration it was the most violent stomach pains I’ve ever had in my life.  All caution was thrown to the wind and doors were thrown nearly off their hinges as I made the mad clench-scramble in an effort to not shit myself en-route. 

The next day I came out of my room and felt better. It was my day to teach TCCC, and I was a Green Beret. I could make it through the day on barely any sleep again. I didn’t even make it to noon. I spent the next 3 days alternating between sprints to the bathroom 20 times a day and bouts of fitful sleep. Rather than get better, I was getting worse. By the 4th night, I had a temperature of 104.8. My junior medic and I decided that if it hit 105, we’d have to enact our MEDEVAC plan, which let’s just say was not ideal. That night I had a fever of 105 exactly, but convinced my junior to wait it out until the morning before I gave up.

I don’t remember what time I woke up that night, but instead of making a mad dash to the bathroom, I was now laying in a pool of water. My first thought was that it was raining and my roof had sprung a leak. I realized after becoming more awake, that what had really happened was that my fever had broken, and my sleeping bag was waterlogged in my own sweat. I felt almost completely fine the next day, minus being a little weak and severely dehydrated. Having been absent for a few days and our soldiers we were training being told I was sick, they brought me food upon seeing me for the first time in days. It was Balut. FML

To be continued with more stories............


Managing Junctional Hemorrhage

Managing Junctional Hemorrhage
We are honored to share a guest write-up by Rob, @rob_o_medic, Senior 18D and instructor on the treatment of junctional injuries! 


The hemorrhage that takes place when a main artery is divided is usually so rapid and so copious that the wounded man dies before help can reach him- Colonel H. M. Gray 1919

Hemorrhage in junctional areas, such as inguinal (groin), pelvic, and under the arms can take more time and expertise to control. These areas can and often should have junctional tourniquets added for additional hemorrhage control. Most medics should know or have heard of junctional tourniquets. However, improvised tourniquets of this nature may be unfamiliar to new medics or civilians who come across an injury that needs one, so we will lay out information as outlined through various reference materials available to service members and civilians alike.
As we all know hemorrhage is the leading cause of preventable death on the battle field. 90% of combat fatalities occur forward of a medical treatment facility. 75% of combat fatalities have non survivable injury and 25% have potentially survivable injury. Of those with potentially survivable wounds, 90% die from hemorrhage. Although bleeding is a main cause of death, the vast majority of wounds do not have life-threatening bleeding. 


Massive hemorrhage tends to fall into two distinct categories:


- Compressible
- Non-compressible


Tourniquet use is great for extremities (compressible) wounds, but as IED's dominate the recent wars, an increasing percentage of casualties present with poly-trauma from blast related injuries rather than bullet or direct fire weapons. Recent statistics show a breakdown of casualties as: 60.5% from Boobytrap/IED and 19.2% from bullet. High junctional wounds (high femoral/pelvic and axillary wounds) do not allow the standard use of a tourniquet. So further considerations must be made to control blood loss to these areas. 


Initial treatment should always be direct pressure and wound packing. There are various hemostatic agents available for use, such as Combat Gauze, Chito Gauze, Celox, and Nu-Stat. Its really shooter preference and what is readily available from your supply folks (what works better can be saved for another conversation). Remember to always find the SOURCE of the bleed and apply direct pressure. 


Attempting Junctional TQ
A transition to a junctional TQ should be considered after manual pressure and wound packing has been attempted and successful. Due to the sometimes long and difficult set up of either deliberate or improved TQ's, the provider should make initial attempts at wound packing, manual pressure at identified pressure points, and if possible, clamping damaged vasculature when readily identified. Be sure to clamp proximal and distally to the damaged vasculature. Use of a Debakey peripheral vascular clamp preferable if you have access to one. 
Managing Junctional Hemorrhage


Generally speaking if you arrive to find ongoing junctional hemorrhage and your patient is alive, you are already ahead of the power curve. We had an incident at Fob Shank in 2014. Some regular army platoon was training at the range. A young soldier got hot brass down his back. Being the undisciplined soldier he was, he freaked out, jerking his arm about with his weapon on fire. He shot his battle buddy in the hip right next to him. The soldier died before he made the 3 min drive to the FST located on base. The point of that story is if the major vasculature of the pelvis is hit, (iliac/femoral arteries) and there is complete dissection of those vessels, there is little you can do about it.
There are three major sources of pelvic bleeding: arterial, venous, and cancellous bone. 70% of the time, blunt pelvic trauma causing fracture is venous and may be controlled with pelvic stabilization. 


Arriving at the patient:


(Pelvic and LE Junctional Bleeds/injuries)
I recommend applying pressure to high femoral with your fingers. It takes little to no pressure to achieve hemorrhage control this way. Medicine is generally not done in a vacuum, so utilize the people around you and replace your hands with theirs so you can control the chaos of treating the casualty.
Once hemorrhage control is confirmed, take a moment take a breath. Release some stress and think about what you are going to do next. Continue your blood sweeps of the patient and then begin exposing so you can visualize what you are dealing with. In training we generally don't make our patients completely trauma naked, but in actual trauma, you need to suspend modesty if it's the difference between life or death. This is important so you can identify what you need to pack or clamp etc... 


Wound Packing-
Choose your hemostatic agent of preference. Pack as much as you can into the wound. Be sure to hold direct pressure for at least 3-5 minutes after application. This is often not done in training, yet is essential in a real life patient. (Training, especially at the school house, is often done on the clock so it creates bad habits). 
Clamping- can be done and should if the major vasculature can be visualized.


Types of Junctional TQ's
SAM JTQ is my absolute favorite for a deliberate TQ.
I love the SAM for many reasons. It has so many uses and provides me with peace of mine that it will remain effective once applied, even after significant jostling of the patient. I am fortunate to have a giant patient population that we can try this on, and I have had the most success with the deliberate SAM. This will always be the one I carry until something else I find works better. 
  1. Works as a pelvic binder
  2. Can be used bilaterally with both bulbs inflated over right and left femoral arteries
  3. The auto stop buckle ensures proper slack is taken out before application of bulbs
  4. Can be used for Axilla/subclavian injuries
  5. Has an auxiliary strap for additional support in pelvic use
  6. Extremely easy to use
  1. It's bulky- (I would hardly consider this a con as I am making sure I have room for this. But many people want to streamline their kits)

Go out and make sure you train with this device and become familiar with it. Common issues I see is applying this device to high. It must lie over the greater trochanter on both sides to effectively bind the pelvic and allow proper placement of the bulbs to gain hemorrhage control. You may need to tie the ankles with a cravat in internal rotation to provide further stabilization.


Improvised JTQs
I have seen many types of improvised TQ's made with the SOFTT-W TQ's. I will lay out a few of them below. I will say these TQ's have a pretty high failure rate, at least from what I've seen in training at the school house. They do not provide me the piece of mind I once had when I first learned these years ago. Failures are commonly seen after patient movement due to it being improvised in nature. Be sure you have proper placement over high femoral area. Take out as much slack as possible and be sure to have the windless directly over where you are trying to provide direct downward pressure. With some of the larger implements used below, there is no pelvic instability, and if the patient permits, some external rotation of the LE may be needed to gain better purchase on the desired pressure point.


SOFT-W with a grenade pouch under the windless and a lacrosse ball secure inside. it provides pretty good direct pressure on the the high femoral area.


SOFT-W with a tightly rolled SAM splint preferably with all slack taken out and taped as to make it as rigid as possible


SOFT-W with a Nalgene bottle underneath


There are other ways to attempt JTQ's as well, such as using cravats! See pic below courtesy of the Special Operations Medical Coalition:
One last note. I am not a fan of placing a knee in pelvis for hem control. If you must and are a lone provider, a knee to the abdomen would be preferred over pelvis. We (the medical community) have also talked about using an AAJT (aortic TQ) as a very temporary stop gap so you can work through your procedures and then take it off. Most folks don't carry these and they are incredibly uncomfortable for the pt. 


Axilla/ Subclavian vessel injuries  
- I won't go into as much detail here as some of the same principals apply when managing this type of hemorrhage. As with above if you can visualize the bleeding utilize manual pressure to gain control of the bleeding. Pressure points are quite difficult in this area especially for the subclavian artery. You have the clavicle in the way of providing adequate pressure. I have seen it done but it takes an incredible amount of pressure and is extremely uncomfortable for the pt. 


Wound packing- Same principals apply from above. If the wound is big enough,  try to pack as much hemostatic gauze as possible and hold pressure for 3-5 minutes to achieve control. If there is no cervical involvement you can perform an X wrap around the body with a large 6in ACE wrap to provide external pressure to the injury. 


Axilla wound- 
Wound pack and take an additional roll of kerlex and place it in his armpit. Use the SAM TQ to secure his arm down to his side. With the added piece of kerlex you will provide adequate pressure to the Axilla to control any hemorrhage. More secure than just trying to use ACE wrap. It's difficult to provide direct pressure. 


The SAM works great but you need to take an additional step. The SAM comes with this wedge device, and it's not ideal. Instead, take a golf ball sized roll of Coban and use that in place of the plastic wedge. Have the pt turn their head and you will see the notch/crease made by the proximal portion of the clavicle. Place the ball there underneath the balloon and you can achieve relatively comfortable hemcon of the subclavian vasculature. 


Squashing a myth
-Subclavian tie off using IV tubing. This has been going around for a while and there are rumors it has been successfully done in the field. This is simply wishful thinking. With right-sided subclavian injuries a median sternotomy can be performed. For Left-sided injuries the use of a median sternotomy is inappropriate. The left subclavian vessels are posterior and cannot be reached through an incision alone. There is a procedure called a trapdoor incision or "book" thoracotomy. These procedures should be left to professionals. Utilize wound packing or a urinary catheter to gain hemorrhage control.
Don't cause more harm to a patient by attempting these procedures.


Pelvic Injury Notes: 

 If time permits, a thorough examination of the pelvis and perineum is required to rule out associated injuries to the rectum and GU/GYN systems which may render FX open. Open injuries have a mortality rate of >50% due to hemorrhage and late sepsis.

Signs and Symptoms to look out for: 

 Length discrepancies, scrotal hematoma, and ecchymosis raise suspicion for pelvic ring injury. Bi-lateral lower leg amputations have a high association with clinically significant pelvic fracture and instability. Don't even waste time checking for stability. If the MOI correlates with associated injuries, go ahead and provide immediate pelvic stabilization. 


Final notes:


Dropping a knee:
I am personally not a fan of dropping a knee into the pelvis. With the types of injuries we generally see that cause pelvic involvement, there is a high index of suspicion that there is pelvic instability. Dropping a knee into a patients pelvis is not good medicine. You are more than likely not actually getting any sort of occlusion to the underlying vasculature.


Use of X-Stat:
Lots of people ask about X-stat. Frankly I don't have any experience using this nor have I gotten much feedback in the positive about that device. I am not ruling it out, but as of right now its not finding a place in my aid bag.


My favorite- I think every medic should carry a Foley catheter in either their pocket or readily accessible on their med kit. you can use if for small wound tracks and stick it in directly into the wound. using saline flushes (preferred over air) fill the bulb  to create a tamponade. Its important to clamp the proximal end of the catheter so as to not allow blood to flow through. 


All treatment considerations come from an operator and instructors perspective. Supplementary information was gathered through Emergency War Surgery book as well as Joint Trauma Service CPG's.