Originally developed by the CDC, the Sort Assess Life-saving Triage...
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Photos by Dave Miller and Erik DaTrek
Medical training hasn’t always been the most popular topic in the survivalist community, with many preppers choosing to prioritize skills that sound more exciting or impressive — the sort of thing you’d see in a James Bond movie rather than a textbook. However, in my humble opinion, medical training is just as important as being trained in the use of a firearm. With a little bit of knowledge and practice, the average person absolutely can render aid in the critical first few minutes of a trauma scenario, and those actions might make the difference between life and death.
We often hear that it takes around seven minutes for an ambulance to arrive on scene. In that time frame, someone could bleed out and die without intervention. A four-hour class on the use of a tourniquet could’ve saved a life. If the scene had multiple casualties, a two-day class could’ve started the process of organizing the scene so that EMS could focus care on the most critical patients. Think of yourself as a pre-first responder. You could make a difference and save someone’s life. Once official first responders arrive, you can hand off, report, and aid as needed.
In an effort to check out one of the “pre-first responder” training opportunities that are currently available, I went to the Northern Woods Training Facility in Luther, Michigan, for Dark Angel Medical’s class, Direct Action Response Training (DART) 2. Kerry Davis was the lead instructor, with Doc Bridger (Mike Rohan) and Ross Francis assisting.
As the name implies, DART 2 is a continuation of DART 1, Dark Angel’s flagship course, covering their version of MARCH (M-massive hemorrhage, A-airway, R-respiratory, C-circulation, and H-hypothermia) and trauma scenarios. This came about as a way to prioritize assessment in the trauma patient and is synonymous with the Tactical Combat Casualty Care (TCCC) training courses that teach pre-hospital medical care in combat/trauma scenarios.
Dark Angel Medical interprets the MARCH acronym in their own way by using HABCDE — Hemorrhage, Airway, Breathing, Circulation, “Da brain,” and Environment. Their version expands upon the original ABC acronym (airway, breathing, and circulation) from basic life support classes. Out of necessity, hemorrhage is given its due place at the front of the line as the largest contributor to casualties in combat. I like that “Da brain” is included in the HABCDE acronym because traumatic brain injuries (TBI) aren’t always detected during initial assessments of trauma patients. The last element, environment, encompasses more than just hypothermia and can bring in to play assessing, or re-assessing, scene safety.
Dark Angel Medical’s Casualty Algorithm:
Another key concept that was emphasized, as the scenarios became more complex, was the use of the color-coding system to categorize, or triage, trauma patients in a mass-casualty scenario. The color coding helps to organize and prioritize what patients need to be evaluated and transferred to higher care. The colors used are Green, Yellow, Red, and Black.
Green is commonly called the “walking wounded,” consisting of minor injuries. When you’re the first to come upon a mass-casualty scenario, you should stand in one place and say, “If you’re able to walk, please come toward my voice now.” These patients are now in one area and may be able to start providing basic first aid for themselves by taking care of minor cuts or injuries. Next, you have to quickly move through the remaining patients to see who falls into the Red category. These patients have life-threatening injuries, such as massive hemorrhaging, and need immediate treatment.
Once relatively stabilized, move these patients to an area where they can then be transported to higher levels of care. Next are the Yellow patients. These are people who may not have immediate life-threatening injuries, but will need higher levels of care in the next few hours. These people could move up to the Red category as their condition changes. Reassessment of these patients is more easily accomplished if they’re all moved to a common area. Black patients are those who have died due to their injuries or whose death is imminent.
The hardest part of this system is hammered home in Day 2, when the scenarios get complex and you’re the one determining triage levels. In fact, Day 2 of DART 2 is all scenario-based. There was no down time, as every opportunity to learn was maximized during scenario setup. The amount of work put into this class was abundantly clear. Nobody came away disappointed and everyone learned something valuable. Here are some of the takeaways from the class.
While the firearms and preparedness communities have an inherent focus on self-reliance, most of society doesn’t. The concept that nobody is coming and that, in an emergency, you’ll likely be on your own, should be embedded in your noggin. Medical training is as important as self-defense or survival training when preparing for threats unknown. We always train as if we’re going to win the fight but what if we, or other members in our cadre, have been significantly injured in an altercation? Without medical training, you’d probably call 911 and wait. Sometimes you wait for seven minutes, and sometimes you wait for 20. In a remote wilderness setting or a widespread disaster, you might not be able to reach anyone for hours or days.
You need to have the mindset that you’re the pre-first responder by starting triage and treatment immediately once the scene is safe. Whether the trauma is a gunshot wound, an edged-weapon wound, a broken bone sticking out of the skin, or some other injury, you can be the difference between life and death if you’ve invested in some medical training. It’s absolutely up to you to get medical training and to carry medical gear every day.
Initial Patient Assessment Questions:
Just as firearm skills are perishable, so too is your proficiency with medical skills. Although you have the ability to put on a tourniquet, how fast can you do it effectively under stress? Can you place a tourniquet with your weak hand only? How about in the dark and upside down while whistling Dixie? No? Well then, keep practicing! During intermediate and advanced medical classes, like DART 2, you often learn the basics of the medical gear and how to apply it. Each of those skills, in turn, becomes part of a larger scenario where you use several pieces of gear during an absolutely chaotic situation.
Above: Students honing their wound-packing skills using Phokus Wound Cubes, as seen in in Issue 28.
The stress is compounded by sensory overload as the scenarios become more complex. These skills, like tourniquet application, chest-seal application, and triage, are all part of the big picture of scene management covered in this two-day class. The bottom line is to keep practicing your medical skills. It’s easy to cut corners when you’ve let these skills perish. Sure, you might get most of the scenario correct; however, the one part you missed could cost someone their life.
Hopefully you have your everyday-carry medical gear (EDC-M) with you at all times. It’s just as important as your standard EDC. Both can be specific to you, your needs, and your training. Neither should be ignored. Maybe your EDC-M is a tourniquet and a cravat. Maybe it’s one or the other. Maybe it includes your favorite clotting agent. If you don’t carry any of it, what’s your backup plan for medical gear? Should you use your belt for a tourniquet? It’s not ideal, but I have one patient who’s alive, minus a leg, because the responding officer used the patient’s leather belt as a tourniquet to slow his bleeding.
Improvising should be a planned alternative in which you’re aware of the risks involved. You’ll also need to pay extra attention to the improvised method and constantly reassess to make sure that it’s working as you intended. That’s not to say that if you used your favorite tourniquet, you shouldn’t reassess, but it becomes absolutely imperative with an improvised device.
Things always change, so we need to constantly reassess the scene, the patient, and ourselves. Perhaps the scene safety has shifted, requiring you to take cover or move the patient to a safer location. Perhaps the patient’s condition has changed, and they’re now bleeding despite having a tourniquet in place. Maybe the patient’s mental status has changed, suggesting a bump up in triage from yellow to red. Taking care of one patient can be hard enough, but when there are multiple casualties, reassessing and communicating are critical.
Unless you’ve trained for a mass-casualty event, it’s impossible to conceive the level of chaos that occurs. By taking a scenario-based class like DART 2, you’ll be more comfortable at managing multiple patients and their injuries. As a result of this element, I think the attendees, including myself, all had a better perspective of the importance of a solid knowledge base, communication, improvising, and constant reassessment in the event of a mass-casualty situation. Be prepared to handle one casualty, but understand there may be multiple casualties. Seek out training to test your skills in complete chaos. You’ll come away with an understanding of your strengths and weaknesses. Practice often, because your level of confidence is guaranteed to diminish without regular refresher courses. Hopefully your skills are good enough to save a life someday.
David L. Miller, DO, FACOI, is an internist in private practice for 20 years. His experiences away from the office have included time as a fight doctor in regional MMA events and as a team physician for 10 years at a mid-major university in the Midwest. Currently, he serves as the lead medical instructor for the Civilian Crisis Response team based out of Indianapolis.