We get asked multiple times a week if we have any advice to give for new 68w, those going to the SOCM course, or those interested in being a medic. We’re going to do our best to help answer some questions, and we’ll continue to add to the list as we think of/get asked new questions and answers.

1) Q) What can I do to prepare for the upcoming SOCM course?

The SOCM course is not a course that you NEED to pre-study for. They do a fantastic job of setting you up for success as long as you put the time and energy into learning it.  We didn’t study for a single day before the start of the course. However, we ended up studying 3-4hrs every night and studying 8-10 hours each Saturday and Sunday in order to pass the tests. REALLY wish we were exaggerating too…but we’re not.  Studying ahead of time would have benefitted us greatly, not only in the depth of our understanding of the material, but potentially the amount of time we had to study each night!

So, what can we do to prepare?

-- Know your Anatomy and Physiology. You do not need to know every single piece of the human body. Don’t even try. You will be far better served knowing the major muscles systems, nerves, arteries and veins, bones of the body, how the body works, sections of the heart, lungs, etc. This is not a complete list, but it’s a GREAT way to start building a foundation of knowledge.

2) Q: What are some good study guides to get me started?

1. There is no one size fits all. However, we do recommend the following books that worked for us.

            A) Anatomy and Physiology Cliff Notes (yes it exists, and yes, it is super helpful)  https://is.gd/L61Nth

            B) Netter’s Anatomy flash cards:  https://is.gd/il6YZR

            C) Anatomy Coloring Book:  https://is.gd/rw8a3Y

     2. If you want to work ahead a bit, the ‘bible’ of Special Operations Medicine is the Advanced Tactical Paramedic Protocols 10^th Addition put out by the Journal of Special Operations Medical.

https://www.jsomonline.org/Journals.php#ATP-P

3) I’m starting 68w school soon. Any advice?

-- Probably the biggest thing that we learned when we joined the military and our subsequent progression through different schools and units was this: Your reputation starts from day one. How you present yourself, how you interact with others, and most importantly, how hard you work will follow you for the rest of your military career. For as large as the military is, someone will inevitably ALWAYS know someone where you are going or currently are.

As an example, we had someone in our basic training class who was disrespectful, immature, and lazy. However, he was an absolute physical stud. We ended up on the same military base, but in different military units, and we ran into him from time to time. He had not changed a bit. Last time we saw him, he told us he was going to the next SF selection class. Interesting…you know what’s also interesting? We were far enough along in our careers where we had really good friends who were on the selection committee…who had ALSO BEEN IN OUR BASIC TRAINING CLASS. Sure enough, he was a non-select. Not because of his inability to pass the physical portions of SFAS, but because his reputation proceeded him.   

Additional pointers: 

-- Make your mistakes in training. Put yourself in uncomfortable scenarios, and never pass up an opportunity for extra practice. 

-- Do not EVER feel you have it figured out. A medic is never off-duty, and no injury set is ever unique. Never stop practicing, never stop drilling. We as medics tend to practice on the same set of injuries over and over again. If we can’t pull ourselves out of our comfort zone and challenge ourselves, we will never progress and advance.

4) I am on the fence about being a medic. What should I know about the job? Is it right for me? We have no idea if it’s right for you. However, being a medic was the most rewarding job we ever had. Using your skillset to return a teammate back to their family is a feeling that cannot be replicated.  To have a chance to kneel over them and see a sense of fear turn to relief because they trust your ability to save their life is not something that 99% of jobs give you the opportunity to do. The only caveat to that? Your job is NEVER done. A gun may not change for 30 years, but medicine never ceases to change and progress.

 5) What was the toughest part of the SOCM/18D course?

Every person will find a different portion of the course to be the toughest. For us, it was the hands-on portion, but for a large number of people, it was the Anatomy and Physiology portion. The A&P part of the course was 6 straight weeks of an absolute firehose of information shoved down your throat. We were told it was comparable to a years-worth of Anatomy and Physiology in 6 weeks, with tests every 2-3 days. Fail 1 test and you had to retake it. Fail it again or fail a 2^nd test (failing was 74.4%) and you were immediately recycled or taken out of the course and re-classed or sent to needs of the Army. Out of class of 72 that started, we were down to 50 after the first 6 weeks. The second biggest portion that got guys recycled or failed was a portion that heavily tested a variety of hands-on skills. You never knew what you were going to get, and you had strict time standards that you had to meet while remembering exact steps within numerous sequences. Miss enough of the small things or any of the big ones, and you were a failure. We graduated 33 people out of a class of 72 for SOCM.

Here is the biggest thing we discovered. You have to work harder and study harder than you’ve likely ever studied and worked before. Not only that, but you have to find it within yourself to maintain that motivation for nearly a year. When you finish though, the pride you will feel is unmatched. This is not meant to scare you, it is meant to give you a realistic look at what is expected of you. You will study for hours each night. You will study on weekends. You will give up your weekends of drinking and relaxing, and you will lose sleep in favor of more studying and practicing. You will likely have bad days, and doubt yourself and if you belong. That is okay. Every single person going through SOCM has doubted themselves at some point. Keep going! 

6) How should I mentally and physically prepare for the school?

-- Develop good study habits. Learn how you learn. What do we mean? Figure out if you are a visual learner, rote memorization (repetitive learning), or other. Do you need notecards for everything? Do you use word association to help you remember things? Finding out how you learn best will help you not waste time early in the course figuring this out.

-- Mentally understand and prep yourself and your loved ones for the time commitment that you will have to undergo in order to be successful.

-- Stay as physically fit as you would in any other school. Just because you’ll be in a garrison environment with mainly classroom sessions does not mean you are not expected to be physically capable of rucking, running and passing your PT tests according to the SOF standard of 270. Every so often they'll give you a PT test, and god help you if you fail. 

7) Are there any good books out there describing the 68W or SOCM/18D course?

No, not to our knowledge. Most references to the SOCM/18D course are paragraphs or blurbs in other books, such as Masters of Chaos, Chosen Soldier, etc.

8) What are rotations like? Rotations at civilian Level 1 trauma centers and local EMS services take place during the SOCM course, and are meant to give you the real life hands on experience you have theoretically only been training on up to that point. You will experience true traumas during this period, where you will be evaluated and gain experience. This was one of the best months of our lives in terms of realistic application of what we had been taught.

Where do these take place and what are the expectations? You'll have to get to that point to find out!

9) Should I pick up your Medic Quick Reference Guides before I join the Army?

With complete honesty, not yet. The Medic Quick Reference Guide and Narcotic Quick Reference Guide will do you the most good once you have started your 68W program or SOCM and have at least a base of knowledge. You can check it out HERE to see if it would be a good fit for you if you've already started school or are currently a medic!

Didn’t find your question here? Shoot us a comment and we’ll add onto this list with our responses! 

Heat Injuries!

During a hospital rotation with the 18D course, I was working in the ER when a soldier was brought in with a core temperature of 108 degrees. We rushed to get his core temperature under control by dousing his entire body with ice and turning on multiple fans. When his core temperature reached 102, myself and the other students wiped the ice off him to begin the slower rate of cooling. Just then, someone else came in and dumped more ice on him, and despite our protests, we were overruled as to these further cooling attempts. This soldiers’ temp dropped all the way into the mid-90’s before they realized their error and tried to reverse the now hypothermic soldier. 3 weeks later when our rotation ended, this soldier was still in the ICU, and his prognosis was not good. Heat injuries are extremely common, and understanding the difference between the different types of heat injuries and can help us identify them early, and render proper treatment. 

HEAT INJURIES 

There are 3 forms of heat injuries. In progression of least to most serious, we have heat cramps, heat exhaustion and heat stroke. The progression of heat cramps to heat stroke can be rapid if not recognized and proper actions taken. Let’s take a few minutes to understand what each of these 3 forms of heat injuries means.

Heat Cramps:

 Heat Cramps are exactly what they sound like. Involuntary muscle contractions, aka cramping. They are most likely caused by an electrolyte imbalance caused by dehydration, heavy sweating, and improper rehydration.

Symptoms:

Heat Cramps are often: Intermittent, involuntary, and painful. When recognized early and treated properly, they tend to go away on their own.

Treatment:

1) Rest in cool place. Drink cool water, electrolyte drink, and/or eat food.

2) Do not overexert yourself or try and return to activity too early.

Heat Cramps can be a warning sign of impending Heat Exhaustion.

Heat Exhaustion:

Heat Exhaustion is the next most serious form of heat injury, and is caused when your body begins overheating. This is most commonly associated with strenuous activity in conjunction with high temperatures and high humidity. Body Temps are often found as high as 103-104 in heat exhaustion, but can be lower and still exhibit some or all of the following symptoms. 

 Symptoms:

- Heavy sweating and rapid pulse

- Dizziness

- Fatigue

- Low blood pressure when standing

- Headache

- Nausea

- Faintness

- Cool, clammy skin

In order to get a proper reading on temperature, take a CORE temp. Do not take an under-the-tongue temp, forehead temp, etc. as it may not reflect what is happening internal to the body. A CORE temp must be taken. 

Treatment:

1) Stop all activity and rest immediately

2) Move to cool place

3) Drink electrolyte fluid and water

4) Do NOT slam fluids down. Take measured sips over time. 

5) Just because you FEEL better, does not mean your body has had proper time to recover. If you exhibit any of the above symptoms, give your body adequate time to recover, and return to activity SLOWLY to gauge your ability to handle the heat AFTER your symptoms have gone away. 

-- If you are unable to drink fluids due to vomiting or nausea, you may need higher medical attention for IV rehydration.

-- Do NOT give too much IV fluid, and do not give it too quickly. Your body can not process more than around 1L per hour, so slamming home bag after bag of IV fluid is bad medicine, and can lead to hyponatremia (too much water/fluids) and cause additional severe problems to the body. 

If Heat Exhaustion is not treated quickly, it can very quickly lead to Heat Stroke, which is extremely life threatening.

Heat Stroke:

The most severe form of heat injury and EXTREMELY LIFE THREATENING

It generally involves a physical collapse or debilitation during or immediately following exertion in the heat. Can be sudden or gradual. Take a CORE temp to determine true body temperature. 

Symptoms:

- Body core temperature exceeds 104 degrees (F).

- Altered mental status, to include delirium, stupor, coma

Treatment and Management:

-- If you haven’t called 911 or alerted emergency services-do so!

-- Cooling should be immediate and primary goal!

(Early rapid cooling reduces mortality and morbidity!!!)

-- Best option for rapid cooling is an ice bath with full body immersion (minus the head)

-- If unavailable, a continual dousing of cold water such as one would experience in a cold shower.

-- If the first options aren't feasible, spraying patient with water plus fanning/rapid air movement across the body can also be done.

CONTINUOUSLY APPLY THESE MEASURES UNTIL CORE TEMPERATURE GOES BELOW 102 degrees!!! Then, continue to cool at a much slower rate, so as not to drop the bodies temperature into hypothermia. 

ADDITIONAL CONSIDERATIONS:

Risk factors to consider with heat injuries:

-- The very young and very old (Under 4 and over 65) have a much harder time regulating their body temperature.

-- Drugs (Prescription and illicit) Blood pressure medications, antihistamines, antipsychotic, and more tend to make your more vulnerable to heat.

-- Obesity: Excess weight can cause difficulty for your body in regulating its heat.

-- Sudden changes in temperature. Moving or traveling from a cold climate to a warmer one can cause lags in your body’s ability to acclimate and adjust its temperature.

-- Heat Index: Be wary of the heat index and limit exposure during most intense parts of the day.

REMEMBER—You tend to run a higher risk of being a repeat heat casualty if you have had it happen before. Your body’s ability to regulate heat takes a hit after a serious heat related injury, and it may take months to recover. Additionally, the factors that led your body to become a heat injury in the first place are often still there, so you still maintain a higher risk factor. Recognize the risk factors in yourself and others, and be prepared to jump in when you see someone who needs your help!

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For more case studies, treatments, breakdowns, etc., please visit other posts in our blog at the following link below, or simply explore our website and the blog! 

For the blog-Click HERE--> Silver Bullet Blog

We help you remember all the SMARCH Steps, Drip-rate calculations, as well as remembering the GSC, 9-line, MIST, Dermatome breakdown, Neuro-Exam, Drug calculation sheet, and much much more, in our Medic Quick Reference pocket guide! We have numerous guides to fit your skill-set and interest!

For the full lineup of our Reference Guides-Click HERE--> Quick Reference Guides

Anatomy and Physics of a Gunshot Wound (GSW)

Gunshot wounds can be devastating. From the immediate impact on the organs of the body to their long-term consequences and lengthy recovery time, no GSW follows the exact same wound pattern. Knowing some basic ways in which bullets tend to operate can help us better prepare for their effects on the human body, and can lead us to be better prepared to assess the ENTIRE body system rather than focusing on the immediate presentation of the individual bullet wound.

A bullet’s damage is directly related to its kinetic energy.

KE = 1/2mv^{2             (}½ mass*velocity^Squared)

What does that mean? It means a small standard 11.9g, 5.56mm (.223) round, fired at 2800fps can cause MASSIVE damage.

What happens as a bullet passes through the body?

- Tissue damage

- Secondary shock wave

- Cavitation

The faster a bullet goes, the more damage it has the potential to do.

How much damage it causes varies by its velocity, where it enters, trajectory, weight and design (7.62 vs 5.56 vs hollow point, .45 vs .9mm etc.)

As a bullet enters the body, it forms a cavitation, or expansion, of the surrounding tissue. It also lacerates the tissue it encounters. The bullet may yaw, or tumble, as it slows, further lacerating the tissue and causing the bullet to follow often unpredictable pathways within the body.

High velocity bullets create a pressure wave, pushing the tissue away from it on entry. The acceleration of tissue away from the pressure caused by the velocity of the bullet will often leave a secondary cavity, often larger than the entry wound. 

This is why you do NOT USE TAMPONS FOR BLEEDING CONTROL!! They do a ‘soft expand’ which does NOTHING for controlling bleeding except soak up blood.

Pic from TriadMedical

So how does a bullet effect some of our major systems?*

Skin and Muscle

These tissues are relatively elastic and therefore tolerate the temporary stretching effect of the cavitation relatively well with limited tissue necrosis. Functionally, injuries to these tissues are well tolerated.

Neurovascular Structures 

Nerves and vessels are often relatively fixed anatomically and therefore are vulnerable to the temporary distorting effect of cavitation. They can remain macroscopically intact away from the permanent cavity; however, intimal damage in vessels and axonal damage in nerves can result in functional failure even some distance from the path of the bullet. 

Bone

The unique strength of this tissue means that it exerts a significant retarding effect on projectiles that strike it. This results in considerable energy transfer, often with extensive fragmentation of both bone and bullet. This follows the potential for these fragments to be accelerated as secondary missiles.

*Breakdown comes from NIH breakdown on GSW, and can be found at following link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4596205/

So what can we do about it?

Understand that bullet wounds can affect multiple systems. If someone is shot, FIND THE EXIT WOUND. If you find what you believe is the exit wound, find the entrance wound. Finding both (if both exist) will help you trace the path of the bullet and begin to figure out where the bullet may have traveled, and what organ systems it may have affected.

Let’s go over SMARCH really quickly, but in direct relation to systems a bullet would affect.

Security/Scene Safety: Make sure the scene is safe and that you do not become a victim.

Massive hemorrhage: Look for heavy venous and/or arterial bleeds. Extremities can receive tourniquets if necessary, inguinal and non-tourniquet areas should be packed and secured immediately. Understand the path of the bullet. For instance, placing TQ on a leg is great, but if you find an exit wound near the hip or higher, you must take into account the possibility of additional bleeding in the hip, intestines, etc.

Airway: Damage to the mouth, nose, or airway cavity is a severe concern, and must be addressed immediately after severe bleeding. A pneumonic we used in the medical course was ‘teeth and tongue intact, no blood or mucous’. If the mouth is severely damaged, teeth are broken, and there is significant blood or debris in the mouth, upgrade their airway asap. If you have the capability of giving a cricothyroidotomy, do so. If not, figure out a way for them to be able to draw in breath, either through positioning, NPA, OPA, etc.

Respirations: GSW’s in the torso are very likely to damage your pleural cavity, lungs, etc. Delay formation of Tension Pneumothorax by placing chest seals on any penetrating injuries, from the top of the hip bone (top of the ischium) to the base of your chin, front and back of your torso. Support breathing as necessary.

Circulation: Bandage remaining bleeds, even if they are only minor. Keeping as much blood in the body as possible can have profound consequences on recovery time and overall outcome. Initiate IV access at this time, but do NOT begin pumping with fluids. Make a plan for fluids and medication based on presentation of patient.  

Hypothermia/Head Injury: Patients with significant blood loss are at a risk for hypothermia, regardless of outside temperature. Keep patient warm and monitor vitals q 5 minutes minimum. GSW’s causing head injury are extremely serious, and noting patient’s condition and any deterioration is vital to follow-on care. Be prepared to position the patient, bag the patient, etc. Always assume a neck injury until cleared.

There are MANY additional steps that were not covered here in the interest of time and information overload. PLEASE continue to research the steps in TCCC.

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For more case studies, treatments, breakdowns, etc., please visit other posts in our blog at the following link below, or simply explore our website and the blog! 

For the blog-Click HERE--> Silver Bullet Blog

 If you would like help in remembering some of the steps, or want to be sure you hit every step, as well as remembering the GSC, 9-line, MIST, dermatome breakdown, Neuro-Exam, Drug calculation sheet, and much much more, think about getting one of our pocket guides! Take a look and see if they are right for you!

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