PLEASE NOTE that this article contains graphic and disturbing images.
This is the second installment in our series on how to treat a gunshot wound. Read the post and increase your awareness in these types of critical situations.
How to Treat a Gunshot Wound
Gunshot Wound Treatment Kit
First things first, we discuss the necessary gear to take care of these issues. So I am going to discuss the items you need for your trauma kit.
I am only going to address the trauma stuff associated with gunshot wound management. When you purchase a brand new first aid kit, open it and look at all the contents.
Ask yourself “Can I replace some of these boo-boo items with true trauma gear?” and the answer is always yes.
Boo-boo items are the six sizes of band-aids, the 1×1 gauze, the 2×3 gauze, the ½” tape roll, etc.
Trauma items make pressure and absorb much blood. So what we want is 1” tape, and lots of it, 4×4 gauze, roller bandages, triangle bandages, and abdominal pads, to cover the entire abdomen if there's a big opening.
Keep the boo-boo stuff and place it in the shooting kit under the first aid area. I will include a list at the end of this article of what I think should be in the trauma kit.
This is not the perfect kit, but it will start you on your way.
The pictures we include here will show the use of the trauma gear, and I believe that it will make more sense to show its use as I explain in written detail.
Things to Include in Your Trauma Kit
Communications with HELP
Let's spend a few minutes talking about getting help to you and yours in the middle of this very serious crisis.
First, make a plan, and part of that plan is to know before a gun is unloaded from the truck, etc. if there is cell phone coverage in that area. You must be able to call for help if needed.
If there is no coverage, and no way to call for help, a plan of what to do is a must and should be discussed with every person on that range.
Know the GPS coordinates for a medical helicopter and local names of landmarks and areas for dispatch to send ground ambulances to you for help. If you are very remote, the ground ambulance and rescue crews can use the GPS coordinates as well.
After we make a plan, everyone is aware and understands that plan, then write down the GPS coordinates, and place them in the trauma kit. Do not rely on the cell phone to be able to read the map coordinates and talk to dispatch or whatever the plan is.
It may be nearly impossible to have the caller making sense of all of this with a victim suffering an abdominal gunshot and screaming their head off in pain. Just write it down.
Application of Aid to the Gunshot Victim
In this section, I will cover the areas of injury treatment. This should keep it all tight and easier to cover in detail.
With compromised bone tissue, the only things we will have available for use in the field are splints and the gear required for splinting.
Let us discuss the types of splinting materials at a short length. There are two basic types of materials that we use in splinting, hard and soft.
Hard splints are talking about sticks or commercial splints that are a fiberglass stick, with padding. For field-expedient applications, Cardboard or SAM splints are considered hard splints.
They are considered hard splints due to the pressure they can apply if secured too tightly.
Soft splints are pillows and blankets. These are best for ankles due to the conforming aspects of the materials.
Don’t let a pillow or blanket fool you. If the placement is directly on the body, they will give excellent support.
The issue with soft materials is they can be very cumbersome and take up massive amounts of space when talking about field items.
The list I provided has cardboard splints, easily made by the shooter and placed around the outside of the shooting kit. The other is a S.A.M. splint. SAM splints are a piece of aluminum with padding and roll up the size of an elastic bandage when new.
I have no idea how they do that from the factory, but when rerolled, they are still very compact. The SAM splint has a unique application: it can be contorted into any shape, like cardboard, and then a crease is placed down the center.
The crease will take a thing about as rigid as a soda can, and make it hard as a rock. When some serious tape like duct tape is used, it will be very rigid, and good for transporting the victim.
Cardboard can act the same. It's very lightweight, shapes to fit, easy to cut, and rigid like a plaster cast.
I strongly suggest keeping both handy. Trauma shears will cut both of them, impaled objects are accommodated if needed, and digits can be left exposed to check for circulation, etc.
One thing that I don’t see covered much when reading about splinting is what if the area is an open fracture. This happens when the broken bone has punched through the skin.
The term compound relates to the issues of the break, so we have bleeding and broken stuff to deal with. If the skin is open and the bone is broken or could be broken, it is treated as a compound fracture.
The bleeding issue is always addressed first, and the splint is NEVER applied until bleeding stops. This is critical.
Apply the splints after the bleeding stops. Do not apply the rigid splint surface over the knots used to secure the bandaging as it will create a tourniquet effect.
If the tape is enough to secure the bandaging, then the rigid splints are put where they are most effective.
If we have massive tissue damage, use the splints to keep the wound from becoming worse by contracting or stretching tissues that are clotting. Splinting works well for a small laceration becoming a big laceration from tearing of the tissues.
When applying a splint, you need to check for blood flow to the rest of the tissues. Pinch the nail bed farthest away from the splint.
The nail bed will blanch out, then release the pressure, and the color will return.
Now we get into the meat of the subject (yes, pun intended).
The main and nearly only word that we need to think of when dealing with soft tissue injury is pressure — direct pressure. Without it, we will lose the battle.
Think of pressure like this, how do we stop a hose from running, without using the valve, of course? Do we cover the end with a towel and hope it will absorb all the water and keep it from flowing out?
Direct pressure is what will stop the blood flow. The body will then attempt to stop it with clotting.
If the injury is too great, the clotting will not be effective, so the pressure must be the deciding factor. The dressing's (the gauze against the bleeder) job is to give the clotting a matrix to start working in.
The dressing also keeps all the nasty from the outside world from getting into the open wound. The bandage (the wrap that applies pressure) is to free your hands to do other things.
So if you need to squeeze the injury like you are trying to choke a brick to stop the bleeding that bandage needs to do the same. If you need to use your knee to stop the bleeding, the bandage needs to do the same.
So, before we carry on with pressure bandaging, the point comes up about so much pressure the capillary refill stops. If the bleeding is that great, apply pressure on it so blood flow to the rest of the limb stops.
If it will take that much direct pressure, then apply the tourniquet. We will cover this shortly.
Pressure bandaging can be a daunting thought. Just wrap a bandage around the area, then pull it tight until the bleeding stops.
This will put direct pressure on the bleeding tissues. If I use a tennis ball to apply pressure to one spot on the arm, that spot has compression, the rest is normal.
That is exactly how pressure bandaging works. Here is the place a first aid misses the mark, we all heard it, direct pressure until our ears bleed.
But how do we practice applying direct pressure?
So, now that we understand direct pressure let’s talk about gaping and nasty wounds.
Think of a gunshot channel and the massive tissue damage of the exit wounds. How can a dressing covering this area on its surface, stop bleeding in a hole that maybe 3 inches in diameter and 5 inches deep?
The horrible answer is it cannot. That gaping hole will continue to do nothing more than fill up with blood and leak blood internally and externally until it eventually stops.
Two things will stop it, direct pressure or the victim runs out. The second is not a good option for a good guy anyway.
So what do we do, we just talk about the tennis ball approach, so we put it in a gaping hole of a gunshot wound when necessary. Now, do not jam a bunch of 4×4 gauze pads into the wound, they may not all be found at the hospital.
Use the big, huge pads, or the roller gauze, get the dressing to the bleeding. Then wrap the bandage around the area, or if the wrapping is not a choice, use the tape, again “like you mean it.”
To make a very direct point, good looking wrap jobs, and awesome perfect alignment splint jobs are cool to look at and cut off 20 seconds after they are taken to the ER. After the doctors fail to admire the perfect wrap job they're thrown on the floor.
What is needed is, pressure = blood flow stops. That is all that matters, never worry about what it looks like.
Worry about if it works or not, then apply for bulky dressing over the wound, and put on more pressure.
Now to talk about tourniquets. Once upon not long ago, we never used tourniquets and these were avoided like the plague.
Then more research has been done, and, unfortunately, our current wars on terror have been the leaders in this field.
The muscle tissue can withstand a tourniquet for 2 hours before tissue damage is beyond help from vascular surgeons and new and improving treatments.
Tourniquet Definition: A device used as a tight bandage for compressing a limb to stop blood flow through an artery or through the veins.
The quick and dirty answer to tourniquet application is = if they need it, use it. There are very few places in the United States that a helicopter can't reach in an hour and deliver the patient to the surgeons in the next hour.
If the victim is bleeding so heavily that direct pressure will not stop the bleeding, they will not be alive to see the surgeon if we don’t use the tourniquet right away.
We have some new products in the EMS world when it comes to tourniquets. The military-style I believe is the best design, tough as it can get and simple to use.
The old school way of using a triangle bandage and a stick works just as well. The one thing to remember is to use a wide area, about 2 inches to keep the tissue damage at a minimum from the tourniquet band.
Secure the stick so nothing but a pair of shears will get it to release.
The pictures will demonstrate the proper application of these subjects, better than over wordy descriptions. A proper class on trauma is the very best way to make sure you are ready for this situation if it ever happens to you or those around you.
There are some clotting agents on the market; again we give our heartfelt thanks to the veterans that became the subjects in this testing during the war on terror.
The clotting agents are excellent at stopping the bleeding. The issue with them is they need cutting and scrubbing out of the wound before performing any surgery.
It may inadvertently make the injury worse. Think of this, clotting agent works kind of like Kitty Litter.
If it needs kitty litter to stop the bleeding, then use it, but scrub it from the wound afterward. And kitty litter does not bind to the tissues like these clotting agents.
Clotting agents are for field expedient care while under fire, and a very long wait for transport, possibly days.
I suggest having this in your trauma kit, but you must know how your clotting agent works. Read the instructions and visit that manufacturer website to learn everything about it.
Again, like tourniquet use, if direct pressure does not stop the bleeding, you must take it up a level, maybe the use of this clotting agent is the best thing for the situation.
There is no way to cover every “what if” here, so you need to make the plan ahead of time. When would you use this intervention vs. that intervention, do not try and “wing it.”
Unfortunately, there is nearly zero we can do about solid organ damage in the field situation. There is little that first responders can do; it’s the surgeons that make the difference for these victims.
So our duty will be to recognize that massive damage could have reached the organs, and get help on the way ASAP. Make sure the responders have the correct location and easiest methods of finding the victim.
When there's a damage in the hollow organs in the abdominal cavity, unless they are hanging out (later) we have nearly zero ability to help these victims as well.
If the hollow organs are in the chest cavity, we may be able to provide some help. If the entry and exit wounds are allowing air to enter the chest, everything will get into the body.
So we will need to use the occlusive dressing. Occlusive dressing just means that air cannot get through it.
If the wound is making a sucking noise, the air is leaving the chest and entering the chest, we need to make very quick action to keep the air pressure from the leaking lung from building up inside the thoracic cavity.
We use the occlusive dressing for either, keeping air from reentering the chest cavity, and to allow air to leave from the inside and not to allow it to be sucked back in.
Place the occlusive over the injury, and tape down three sides. This will allow air pressure from the thoracic cavity to leave and work like a “flapper valve.”
When sucking the air back into the chest cavity, the occlusive will pull against the wound and stop the airflow.
The EMS world also has a piece of equipment for this; it’s called a chest seal. These are priceless for dealing with gunshot wounds.
They are an all-in-one unit, they will adhere to the skin, and the “valve” effect built-in, and works nearly perfect. Nearly perfect, because in EMS nothing ever works perfectly for every situation.
Evisceration is the hanging out of the abdominal cavity for hollow organs.
Eviscerations are very shocking, even to watch a movie; they make everyone cringe away.
Filed treatment of evisceration is a matter that needs immediate care. The organs are not pushed back into the body.
The exposed organs need to be kept wet, warm and sterile – as much as possible. Place a large gauze pad over the organs, wet it with the cleanest water available to you.
Then cover the entire thing with the occlusive dressing to keep the gauze from drying out. Another purpose is to keep the area clean as well.
Tape all the sides down, so things don’t leak out or crawl in. The exposed organs can die as soon as they dry out, and the victim right afterward.
I cannot stress the importance of good, high-quality trauma training is for shooters. This skill is necessary at any level of the sport.
Find high-quality gunshot wound first aid training near you. Take an EMS class and get your certification.
It is the best money you will ever spend, and this subject is just a sliver of what you will learn. Not all EMS people work in the field, there are many that have taken this training and had it as a preparedness skill, and I can whole heartily agree.
Check out this short video by City Prepping on how to build a gunshot wound trauma kit:
If this ever happens and you find yourself in neutral, just start doing something. To make sure that neutral thing never happens, make a plan, get the training, and be readier for it to happen than you may think you need.
Remember the beginning of this article, the caller was sitting on his couch, not on the firing line, not hunting, just watching TV, and it nearly cost him his life. Don’t be a tragedy, be the difference!
Did you get the information you need for treating gunshot wounds in this article? Share your thoughts with us in the comments section below!
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Editor’s Note: This post was originally published on July 29, 2015, and has been updated for quality and relevancy.