Back in November I took Suarez International Trauma Care for Shooters taught by Karl Johnson in Blairsville, Georgia. Tactical trauma care was an area I'd identified as a hole in my skill set quite a while ago, and I'm not alone. We all love to train to do cool, fun stuff like shoot and stab people, but learning how to patch up the holes after a fight never seems to be a priority. This was the first opportunity I'd had to take a class like this and wanted to jump on it.

The class was fairly small, just seven students. Quite a few of them had been to Karl's one day tactical trauma seminar during Warrior Skills Camp last July, and the fact that they showed up for the two day version this speaks well of his teaching skills. This also was my first opportunity to meet Rick Klopp, who was hosting the class. I'd had an online acquaintance with Rick on Warrior Talk for a while now, but this was the first time I'd met him in person. It was also a chance to renew my acquaintance with a couple from South Carolina who I'd met at Tom Sotis' knife class back in June.

The venue for the class was, Camp Jabez, a small summer camp type facility in Blairsville, Georgia. For those who opted to stay at the camp, we got bunks in a bunkhouse and all of our meals for less than the cost of a room at a local hotel. It's a really nice facility, and has everything you could want except a shooting range. For the live fire portion of the class we relocated to a range about fifteen minutes away. Most of the class met for dinner at Camp Jabez on Friday night and enjoyed some good conversation over a nice meal before adjourning upstairs to watch a Systema DVD.

Saturday

The first day was mostly classroom lecture, with the hands on portion of the class on the second day. Karl began with his bio, which is pretty impressive. He's been a police officer, SWAT team member and medic, a contractor in Iraq as a medic and team leader on a personal security detail, and is currently an ICU nurse. He is extremely qualified to teach about tactical trauma care, with a wealth of hands on experience.

He began by talking about what we would learn in the class. The Army talks about Tactical Casualty Combat Care (TCCC) in terms of 3 phases: care under fire, tactical field care, and casualty evacuation. This class was primarily focused on the civilian context, where we can usually rely on an ambulance to show up and take care of the evacuation phase (there are exceptions of course, if you're way out on the boonies, or in the middle of a big disaster like Hurricane Katrina evacuation may be a long time coming). So we spent most of our dime talking about care under fire, and tactical field care.

Karl emphasized that nothing we were learning in this class was intended as a permanent fix. The goal is to keep someone's condition from getting worse, or slow down the rate they are getting worse, long enough for help to arrive and get them to a hospital.

There is a difference between tactical trauma care and first aid. Tactical trauma care is much narrower and more focused. Its pretty much confined to treating wounds from firearms, knives, and blunt objects. Even within these categories, we're only really concerned with wounds that we can do something about. Some injuries just aren't survivable, even if they occurred in an operating room with a trauma surgeon standing by. This class concentrates on wounds that where what we do can make a difference. Unlike first aid, it's usually pretty obvious what the problem is, allowing us to dispense with a lot of the diagnostics associated with normal first aid. If you find someone lying on the ground outside your office, it could be anything from a heart attack to a drunk sleeping it off. In contrast, if a someone goes down during a gunfight, we can make a pretty good guess as to what happened.

Another difference Karl really stressed is that "Scene safety" has a very different meaning in tactical trauma care than it does in first aid. Rather than being concerned with primarily environmental problems like downed power lines, we are concerned with someone who is actively trying to kill us. As long as the fight is still going on, putting your head down and working on a wound could leave us very vulnerable. This means that sometimes the best thing we can do is to ignore a wounded comrade and finish the fight before turning our attention to them. This is really the distinction between the care under fire and tactical field care phases.

Karl explained the biggest threat from the kind of penetrating or blunt trauma we expect in a fight is blood loss. There are some other secondary things to worry about, but blood loss is what kills quickly.

When I was a Boy Scout earning my First Aid merit badge (circa 1990) I was taught that a tourniquet should be a last result, and would almost always result in the loss of a limb. Karl explained that this was probably correct if you used something like a bootlace that applied pressure to a very narrow area. However, a proper tourniquet, at least one inch wide after application, wouldn't result in any permanent harm. Tourniquets are being widely used in Iraq and Afghanistan and are generally the first line of defense against bleeding extremities.

Karl talked a bit about hemostatic agents (such as QuickClot). These have grown increasingly popular in recent years, so much so that some folks seem to think some sort of hemostatic agent is all you need or should be the first choice for every wound. Karl's view, on the other hand, is that hemostatic agents are useful, but more as a last resort, for wounds that aren't in a position where a tourniquet is useful and can't be controlled with direct pressure. He said he doesn't carry any sort of hemostatic agent in his car trauma kit.

While most techniques for dealing with blood loss are aimed at stopping any more blood from being lost, IV fluid replacement can actually increase volume and raise an injured person's blood pressure back towards normal levels. However, while IV fluids can help with dangerously low blood pressure, they don't carry oxygen or clot (in fact, they can make clotting slower and more difficult). Several years ago, the Army emphasized IV fluid replacement in it's Combat Lifesaver classes and employed it aggressively in the field, to the point that some soldiers were coming into hospitals "bleeding pink". In recent years, they've moved away from this and are placing much more emphasis on preventing blood loss through tourniquets and hemostatic agents.

With discussion of some of the more high speed low drag techniques out of the way, Karl moved on to the most basic procedures for stopping bleeding: direct pressure. One of the things he really emphasized that I hadn't appreciated before this was that direct pressure involves more than just shoving down on the wound. It's a three dimensional concept. If you've got a linear, v-shaped wound, you need to exert pressure directly onto the exposed flesh on both sides of the wound. If you've got a big crater, you need to provide pressure in all directions. The way to do this is to pack the wound with gauze, then apply a tight pressure dressing to provide that pressure and keep everything in place.

Blood loss is the most immediate threat, but Karl also went over some longer term consequences of violent trauma that could develop if help takes a while to arrive. A tension pneumothorax is a condition where a puncture allows air to collect inside the chest but outside of the lung. This prevents the lung from inflating properly, making it difficult to breathe. This is the classic "sucking chest wound". A hemothorax is similar, but involves blood instead of air. The accumulation of air can actually start shoving the heart over so it impinges on the other lung, eventually resulting in death.

As immortalized in the movie Three Kings, the treatment is to jab a needle into the chest and let the air out. Karl explained where and how to do this, but he didn't recommend trying it in most circumstances. He doesn't carry a needle for doing this around on a regular basis because the condition takes tens of minutes or hours to develop, by which time the ambulance has probably arrived. You can bandage a chest wound using an occlusive dressing (a fancy way of saying tape something airtight over the wound) to keep any more air from getting in, though this won't help with any air that's already there. Most useful is to be able to describe the symptoms to the paramedics so they can recognize and treat the problem quickly. Besides the bubbling chest wound itself, the main sign of a pneumothorax is difficulty breathing after some sort of trauma to the chest that gets progressively worse.

The other longer term problem we discussed is shock. This doesn't refer to the psychological shock someone might experience after a gunfight, but hypovolemic shock. Essentially, shock is the body's reaction to loosing too much blood. Obviously, the best way to prevent this is to minimize blood loss in the first place. However, we also talked about treatment for shock if it occurs, which basically involves keeping the victim lying down with the feet elevated (unless they have a wound to the torso or chest).

So how does Karl apply these techniques apply in the TCCC care under fire and tactical field care phases mentioned earlier? During the care under fire phase, when the fight is still going on, there isn't really time for packing wounds and applying a pressure dressing. Tourniquets are quick to apply and can prevent someone with a wounded extremity from bleeding out. If you're wounded but still capable of putting on a tourniquet and applying direct pressure, it's time for some self aid. Depending on the severity of the wound, it may be possible to get back in the fight, or at least move to cover and be ready to defend yourself as best you can. If someone is wounded and unconscious, there may be time to slap on a tourniquet and drag them out of the line of fire, but not much else. Finishing the fight and keeping the BG(s) from wounding or killing more people takes priority.

After the fight immediate fight is over, either because all the opponents are down, the cavalry has arrived and secured the area, or active combat has just moved to a different area, it's time for some tactical field care. Pack wounds and apply pressure dressings. As time passes, watch for signs of shock or a pneumothorax.

To round out the lecture portion of the class, Karl broke out a bunch of different tourniquets and pressure dressings from his bag of tricks and opined a bit on the merits and drawbacks of each. The different brands of pressure dressings pretty much follow the same pattern: a stretchy, ace bandage like wrap with an absorbent pad, some method of applying pressure to the wound, and some way to secure the end. While they're generally similar, Karl particularly likes the OALES bandage, because it includes 3 yards of gauze (one less package to open) and has little velcro strips at intervals along the bandage to keep the end from completely unrolling (dealing with the tail as you try to wrap can be a pain). We also went through some of the different tourniquets, but I'll save discussion of those for the Sunday part of the writeup when I was using them to cut off circulation in my extremities.

With that, we adjourned to the chow hall for a nice dinner. Tonights after dinner DVD: Big Folder Fighting Skills by Gabe Suarez (though we spent as much time watching Rick's impromptu knife defense lesson as we did watching the DVD).

Sunday

After a hearty breakfast, we dove right in to the hands on portion of the class. After a bit of review of material from yesterday, we spent the morning trying out various kinds of tourniquet. We applied the tourniquet to our arms and legs, both our own limbs (self aid) and other people's. Once the tourniquet was applied, we (or rather, people in the class who were better at it than I am) felt for a pulse to see if it was tight enough to actually stop bleeding. For these exercises, figuring out how much pressure was enough to do the job was kind of difficult. Of course, in real life, the spurting bleed from an artery will make it pretty evident if you haven't cranked the tourniquet down hard enough. Repeated tourniquet application did not lead to any lost limbs, but they do a pretty good job of simulating a limb disabling injury when they're cranked down (if you can still use the limb normally while the tourniquet is applied, it's probably not tight enough.

First up was the classic tourniquet improvised from a triangular bandage and a stick for a windlass. We tried this both using another bandage to hold the windlass and using the small ring off the top of a soda bottle. This method was the most difficult, took longest to apply, and the hardest to effectively stop blood flow with. Applying it one handed is effectively impossible. If you have two hands available, it can be made to work, but it's definitely not the best option.

Our next tourniquet was the TK-4. This is basically a length of 2" wide elastic with hooks at either end (think of a wide, flat bungee cord). It can be applied one or two handed. It's effective, can get it really tight, but you have to make sure to really crank on it, particularly the first few turns around the limb. On the plus side, it's very small and light, easy to slip into a pocket. At $7 a piece, it's also easy to have a bunch stashed in different places so there's always one available.

The last two tourniquets we looked at were the Combat Application Tourniquet (CAT) and the SOF Tactical Tourniquet (SOFTT). The CAT is, the current U.S military issue, while the SOFTT is currently in use with various special operations forces. The two tourniquets are quite similar. Both can easily be applied one handed and have a built in windlass allowing them to be cranked down hard quite easily. The CAT is a bit more compact, but it relies on velcro and is set up slightly differently for one handed vs. two handed use. The SOFTT has a metal buckle rather than velcro, but it's a bit more difficult to secure the windlass, especially one handed. I like the CAT a bit better, but they're both quality pieces of kit that are very easy to use and effective. The only downside is they're about $30, which makes it more difficult to stash a bunch.

Karl also had an odd tourniquet with a plastic ratcheting design, but it was worn out enough it didn't really work right so I can't really give a good evaluation (I never even wrote down the name of that one).

After a fun morning of tourniqueting each other, we enjoyed a nice lunch courtesy of Camp Jabez and packed up. A few of the students had to depart early, so we were down to four for the afternoon's activities. After giving one of the other student's motorcycle a jump start, we headed out to the range about fifteen minutes away. The range is one used by the local Sheriff's Department. It's in the middle of some fields so we did our training to the mooing of cows (much nicer than the donkey in the next field during Extreme Close Range Gunfighting class).

For the live fire part of the class, Karl handed out folded three by five cards with an injury written on them (something like "Left Leg Heavy Bleeding", for example). If he called out that we were injured, we were to safe or holster our weapons, fall down, and read the card and respond appropriately.

The first scenario he ran us through had a pair of shooters walking through the mall when terrorists open fire. On command, we started shooting the targets and had to keep fire on them (the start signal was often Karl letting loose a few rounds from his AK into the berm). Karl called out a number, indicating which shooter was wounded and that student had to holster, drop, read his injury, apply a tourniquet if appropriate, and drag himself to cover if possible. As this was still the care under fire phase, the other student's job was to move aggressively to finish the fight by putting more rounds into the BGs. After Karl called out that there were no visible bad guys, the other student could come over and start helping with treatment by packing the wound and applying a pressure dressing. We ran the drill several times, so each shooter had the chance to be both the injured and non-injured member. When Rick was the injured student Karl called out that they bad guys were coming back during the tactical field care phase, so Rick was lying there leaning out of cover laying down fire with his Glock while the other student tried to finish bandaging his leg.

After the two man drills, we moved on to a three man exercise. The premise this drew on Karl's time in Iraq: we were were part of a PSD pushed out to provide security and came under attack from insurgents. Karl called out one member to be wounded, and had to provide self aid and find cover while the other two continued to fight. Once the immediate fight was over, one got to work bandaging up the wounded member while the other provided security.

We were generally all pretty good at finishing the fight if we were not one wounded. In all of these drills, communication was key. That said, more communication wasn't necessarily better. If you were hit, calling this out to your partner may just be a distraction to him. On the other hand, once the immediate threat ends, communicating who's injured and how is important.

A three man team really helps. It provides twice as much firepower after someone's been hit and it makes it possible for one person to be dedicated to security while another attends to the wounded during the tactical field care phase. On the other hand, having three people makes communication even more critical. While we were all fairly good shooters and safe gunhandlers, I'm pretty sure Rick was the only one with any real team tactics experience. This kind of limited what we could do as far as being a team goes, both because of lack of knowledge and safety concerns. I could see some of this stuff going really well integrated into a team tactics class.

Since we were all fairly experienced when it came to the firearms end of things, the live fire exercises went a bit faster than Karl planned and we wrapped up about 4:00. We spent some time talking, and each of us had a chance to put some rounds through a student's Suchka. It's really a nice little rifle, but I think we established that it needs to booster on the muzzle rather than a slotted flash hider to function properly, and the LaRue medium height Aimpoint mount is a bit too high for a good cheek weld.

Conclusions

This was truly an excellent class. Karl has a lot of experience and he's quite good at conveying it to students effectively. He does a good job of explaining the context of what he's instructing us to do and helping the students understand why we're doing these things, not just what to do. The first day of the class is a bit of an infodump, but there's a lot to cover and Karl is thankfully an engaging and effective lecturer. Something to take notes on is an absolute must! I think I took more notes in this one day than I have in any other tactical class I've taken. The hands on stuff was really great, and I think Karl does as good a job as can be done without some actual trauma to patch up (which, thankfully, we didn't have).

I would highly recommend Karl's trauma classes to anyone. More than that, this class has only reinforced my belief that some sort of trauma class is an absolutely vital piece of education for anyone who intends to use a firearm for self defense. Many of us spend a lot of time taking fun classes; high speed low drag stuff where we get to shoot a lot and do all sorts of cool stuff. More pedestrian classes like trauma care tend to fall by the wayside. If you are in a gunfight, no matter how good you are, there's a decent chance than you, or a loved one, will get shot. Even if you aren't in a gunfight, every one of those cool classes, every match or practice session at the range is an opportunity for a nasty accident. We try to minimize the risk, but we still need to be prepared to deal with it if it happens. In my opinion, everyone who's serious about shooting and firearms self defense really needs to take a class like this.