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Get multiple doses out of an Epi-pen.

Anaphylaxis can be a scary encounter even when 911 is a few minutes away. In Austere medicine, where patient evacuation is delayed, not on it's way, or you are the medical professional sitting on this patient, a serious situation just became worse. When you give your initial intramuscular injection for anaphylaxis, there is about a 20% chance you patient may need another dose, but you only had one Epi-pen... What now?


A consideration for austere management of anaphylaxis

  Anaphylaxis can be a scary encounter even when 911 is a few minutes away. In Austere medicine, where patient evacuation is delayed, not on it's way, or you are the medical professional sitting on this patient, a serious situation just became worse. When you give your initial intramuscular injection for anaphylaxis, there is about a 20% chance you patient may need another dose, but you only had one Epi-pen... What now?

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  There is enough for around 3-4 doses in the epi-pen still left. I'm going to show you a step by step process in basic terms to be used in emergency situations only. For Medical Professionals and Providers, before you throw out the expired epi-pens, it's free training to take one apart and see how it's done. IMG_9768SAFETYOFF1stDOSE

Step 1.) Loosening the shell.

  We're starting from the point where you've already removed the blue safety and administered the first dose. Your clinical judgement has led you to decide you need to administer another dose. You can use a knife, multi-tool, pliers or what you have on hand to loosen/pry the four corners around the core, as you keep the orange tip away from you to prevent accidental 'stick' with the used needle.   You are loosening the transparent case from the white core for the next step.

Step 2.)   Pulling the white core out of the transparent sheathe

  Now that the outside is loosened, pulling the internal parts of the Epi-pen out will be easier. It may take a couple minutes and some wriggling back and forth. When on it's way out, the spring may cause the white core you're grabbing to spring out. To avoid parts going all over the place you can pull down with the orange tip facing up. After the spring comes out, the only thing left inside should be the syringe of epi and it's needle. [gallery size="medium" ids="1747,1749,1750"]

Step 3.)   Identify and prepare needle and syringe:

  The only thing left inside the epi-pen should be the syringe and needle. You can see for yourself how many doses are left.  It's important to note that the needle is covered in a gray sheathe and to avoid sticking yourself. You will want to remove the gray sheathe carefully. The 'plunger' is opposite the needle and will be used to draw air into the vial of epi as well as push more epinephrine into the anaphylaxis patient in the next step. [gallery size="medium" ids="1752,1753,1758"]

Step 4.)  Administering a dose:

  The plunger should come already pushed down to the stopper due to the initial dose given to the patient.   Point the needle up in the air and draw air into the needle until the rubber part of the plunger is near the back of the vial that holds the epinephrine. CAUTION,  if you pull the rubber part of the plunger back too far, you could pull the plunger out of the vial and leak the precious epinephrine out of the back!   Once you have air drawn in to the syringe, you will administer the second intramuscular dose to the patient. The air is mainly to replace pressure, because the plunger has the stopper and can not be depressed past that point, so you need to draw the air in, in order to push more epinephrine out. This can be repeated 3-4 more times depending on how you measure it.

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  Don't worry about a small amount of air getting into your patient, contrary to popular belief, you need a lot of air directly into a blood vessel to begin to risk that. It's especially negligible when we're talking about the tangible danger of anaphylaxis and anaphylactic shock. [caption id="attachment_1758" align="aligncenter" width="400"]IMG_9804INJECTIONSIMULATION Pushing the epinephrine out is easy. After each dose, the needle will become more dull and possibly increase the pain of the insertion.[/caption]   Between doses when you need to move the casualty for patient transport, as well as when all the doses are used up, place the syringe and needle back in the case for safe transport. Continue evacuation, as mentioned in the article: The Scary Reality of Casualty Evacuation to a higher level of care
References: Epi-pens Website, Reference and Videos - Biphasic Anaphylaxis -

  [caption id="attachment_981" align="aligncenter" width="640"]Firearms, Tactical & Defense Training Firearms, Tactical & Defense Training[/caption]

Vented or Occlusive Chest Seals?

Don't get hung up on the medical words, but we'll have you understanding how to and why you treat a gunshot wound to from Neck to Naval in no timeSuckingChestWound

A Consideration for Austere Management of Sucking Chest Wounds

     Today we are going over one of the leading preventable causes of death on the battlefield: Tension Pneumothorax. Don't get hung up on the medical words,  we'll have you understanding how to and why you treat a gunshot wound from Neck to Naval in no time. The battlefield sets the example for first line care because we learn from our mistakes and translate them into the civilian care. The front line medics are expected to uphold the standard in Austere Medicine where they don't have an ambulance but just the supplies on their back. However, not just the Combat Medics on the battlefield are trained, but non-medical professionals are being taught how and why to save lives in first aid.  This is where the Austere Medical provider comes in, when 911 is not coming and you have to treat and get them to the next level of care by yourself or with the assistance of your Emergency Action Group. Before we can go over how to treat, we must understand "why" we are treating: pneumothorax

 "What is a pneumothorax?"

   As the picture above demonstrates, you have a wound from you neck to your naval, letting air go out of the hole(s) instead of out of your mouth, which is not good. You won't get quality oxygen where you need it and pressure may build up putting pressure on the lungs and heart until failure.

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"Why should I be worried about a pneumothorax?"

    From hunting accidents, negligent discharges on the range, to active shooter and self-defense situations, we may get injured ourselves and that is just including gun shot wounds.  In addition, if Tension Pneumothorax is the second most preventable cause of death in the battlefield where we wear body armor, it's even more likely in an austere situation where we likely don't have body armor. Some medics do not see chest wounds progress from open to tension pneumothorax due to it taking awhile to build up but we have short evacuation times in Iraq/Afghanistan. When it often takes less time to get a bird overseas than it does to get a bird or ambulance in the states, this is another reason to consider this injury a priority where 911 is not coming and this injury has more time to manifest.
" So how do I treat it? I see Vented and Non-Vented Chest Seals." [caption width="300" id="attachment_1484" align="aligncenter"]sucking-chest-wound4 Taping three sides and leaving a corner to vent is an outdated method.[/caption]   If you look around you'll see many variations of the chest seal over the last decade. Occlusive Dressings, Taping on three sides, burp valves and other vents. I'm here to make sure you have an educated decision. This is not a guessing game on what might work, these chest seals are all rigorously tested both on and off the battlefield from U.S. Army Institute of Surgical Research (USAISR) to Committee on Tactical Combat Casualty  Care (CoTCCC). They came out with some new updates, which is important because just because you take a medical class in 2006 does not mean you are "set" and never have to take one again. Doctors take continual classes every year to stay on top of what is current, so when it comes to First Line Care, you should have the same mentality that what is best changes. An emergency is not the time to attempt outdated care or try to save a few bucks by getting a knock off or older chest seal. Using what you have available as a contingency and preparing ahead of time are two different aspects; you know if it was you that was wounded, you would want a superior product: [caption width="300" id="attachment_1483" align="alignleft"]Hyfin Vent Chest Seal in Use Hyfin Vent Chest Seal in Use[/caption]   We have been using occlusive (non-vented) dressings which would trap in the air and increase pressure in the chest cavity AKA Tension Pneumothorax translated simply to "Pressure from Air in Thoracic Cavity." By using a fully occlusive dressing you could take a bad situation like an open pneumothorax and make it into a more lethal Tension Pneumothorax. Instead of letting air escape out of the wounds hole, you are now trapping the air inside, inflating the lungs cavity much like a tire. With a vent you let out enough air to avoid the tension while still assisting proper ventilation through the windpipe.    The CoTCCC guidelines quote, " All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal. "

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   Occlusive Seals are proven to work, for those who are trained and ready to recognize when to do a Needle Chest Decompression (NCD). If you use an occlusive dressing, be prepared to perform a needle chest decompression. For someone unprepared to perform an NCD, I recommend getting the Hyfin Vent Two-Pack Instead. If you're dressing has a "burp" such as an Asherman or Bolin, I'd recommend switching to the more reliable Hyfin Vent as well due to the three-vents offering more redundancy when it comes to getting clogged up by debris or blood. If two of the vents are completely occluded, the third can still function enough to work. Final Tips: No matter which chest seal you use,  Petrolatum Gauze ($3.99) , HALO XL, Hyfins, or any other method,  I have a bit of advice:
  •   Prepare your site! Use your sleeves, gauze or clothing to dry the sweat or blood from where you are about to place it. If the patient is hairy, you definitely need to dry it because the hair can make it even more difficult to get on and stay on.  Don't throw it on there in the heat of the moment and cause your intervention to fail. Take  deep breath, take a second and properly dry your site with whatever you have available.
  •   When you find the sucking chest wound during your Trauma Patient Assessment (Click here to see how) , you can use the back of your hand, not palm to cover the wound with your gloved hand. This frees up your fingers to help open the packaging while you prepare your supplies while having the added benefit of making it less likely bear weight on that arm and 'push down' on your patients wound if you have to reach or lean across them.
  •  You've run out of chest seals, had a mass casualty, or your original came off during transport. What now? Use the package it came in as an improvised occlusive dressing and tape it down.
  •   As always, the equipment is only as good as the training. You can use tape and the packaging to practice covering a chest seal for the low-cost of tape. "Dry Firing" isn't only for Combat Marksmanship , It's for Medicine, too!
[caption width="400" id="attachment_1488" align="aligncenter"]Crisis Application Group's Hyfin Vents: 2 for Crisis Application Groups Hyfin Vents: 2 for $14.99. (Click the picture)[/caption]

Irrigating a wound in an austere environment: "The solution to pollution is dilution"

  It must be said, always seek medical advice and a higher medical authority, but now that is out of the way. For those of you who are new to this, before you learn to suture, you need to learn wound care. Treating an open wound is a direct testament to,  "An ounce of prevention is worth a pound of cure." Aggressive irrigation is a basic, low-level medical intervention that is cheap and simple to perform. What's not to love? Your first response can save the wound from being infected, needing further antibiotics, or possibly having to go back in and debride or cut away tissue that isn't healing well. I find some new to the austere medical community are infatuated with doing sutures, yet don't know how to properly irrigate a wound... That is a recipe for infection and why we are here to talk about Irrigation, Irrigation, Irrigation.

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  Irrigation is flushing  wound with water in order to get all the "bad stuff" out. With an open wound such as a laceration (cut),  Keep in mind the saying, "The Solution to Pollution Is Dilution." running_wound_care3   It means don't be skimpy with your flushing, use a ton! Your skin protects us from many foreign bodies we take for granted, so when the skin is opened up, we need to be there for the wound. You now know the "why" of irrigation, next I'll go over some cost-effective and simple methods to irrigate wounds.

      " What fluid do I use... Normal Saline, Purified Water, or anything available?"

Normal Saline:  In an Austere environment, we don't have the luxury to stockpile Normal Saline and do an irrigation as clean as we'd like in a hospital room. It's simply not cost effective, or worth its weight in a Rucksack as far as I'm concerned.  Many studies have come out referencing potable water's effectiveness rivaling, if not exceeding the effectiveness of N.S.

Purified Water: If you have enough stored, I'd recommend "Pool Shock" granular calcium hypochlorite over Bleach. Both work just fine, however Bleach has a short shelf life of around a year as opposed to nearly a decade with properly stored pool shock. While boiling water is the best for purifying drinking water, you may not have those capabilities for wound irrigation on you.

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⦁ Non-Potable Water: Water that is not safe for drinking or has not been tested or purified is still good to go for wound care if you have to in an austere environment. The benefits of a flush from a non-purified water source outweigh the risks. The benefit with using a local body of water or other source is you are not as worried about wasting a finite resource and can afford to be as aggressive as needed.

  As you can see, it's not a big deal about how purified the water is or what is in it. You want to use a ton of water and most importantly you want to create enough pressure.  I recommend you act like you KNOW something is crawling around on the surface, so you don't underestimate how much you need. [caption id="attachment_1411" align="aligncenter" width="300"]2315700 Povidine iodine solution[/caption]

" What can I use to irrigate this wound?"

  1. The most obvious choice is using a syringe as previously shown in previous pictures. If it's not an Irrigation Syringe, using an 18G-20G catheter will increase pressure more than using the syringe by itself. When using a Catheter on a syringe to draw your irrigation fluid, hold it approximately 1/2" to 1" inch away from the wound and steadily keep pressure. Whether a syringe is 10cc, 30cc or 60cc or any other size, it can be used for many roles and is an easy addition to any medical kit.   2. A second option would be using a bottle, preferably 2L but smaller can work, too.  Poke a couple of holes, but keep them small so you can still maintain high pressure by squeezing the bottle.   Remember its the turbulence that knocks loose the sticky stuff, that's why we strive for a jet like stream when we irrigate. two-holes-drilled-into-lid-of-bottle

[caption id="attachment_1412" align="aligncenter" width="271"]    ( Urine not recommended for wound irrigation, This is purely comic relief ) ( Urine not recommended for wound irrigation, This is purely comic relief )[/caption]   There are endless ways you can improvise, even an old fashion turkey baster and flavor injector will work. This is less about a strict set of ways and more about getting the job done right. After the thorough cleaning place a clean bandage on the wound; Now find a Medical Pro, Get Them to One, or Be The Medical Pro, as discussed in the article: "Where Are The Doctors? The Reality of Casualty Evacuation in an Austere Environment." [caption id="attachment_981" align="aligncenter" width="300"]Firearms, Tactical & Defense Training Tactical Ranch: Firearms, Tactical & Defense Training[/caption]

Every Day Carry (EDC) Tourniquets: What you may need if you have to draw your firearm

"Medical and trauma emergencies are the most likely crisis that you and your family will face in any emergency. If we look at the all the recent catastrophes faced by our great nation one thing stands out as the most experienced event; TRAUMA. It doesn't matter if it’s a chainsaw accident, tornado or a gunshot wound. Life happens and you need to have the right gear. "

  A firearm is the first object that comes to mind when an EDC or "Every Day Carry" list is mentioned. While I've seen card sized items and flashlights commonly added to most EDC's since then, there's a vital piece missing. We can agree that our EDC, especially our firearm, is to get through an emergency and protect ourselves and others...  But what if that does not go as planned?

Tourniquets came in useful for civilians during the Boston Bombing
The Boston Bombing: A testament of the effectiveness of tourniquets outside of the battlefield, as well.

In a situation where firearms or other weapons involved, the optimal end result is that the threat is taken down, good guy escapes unharmed. Unfortunately, you and I both know that with the nature of ballistics and a high adrenaline moment of stress, that this may not be the case.   Even if you have to remove your weapon from the holster, you or your loved one may be harmed in the process eliminating the threat, or you may even have shot a bystander in the process. Unless a paramedic is thirty feet away, that person may very well bleed out long before medical attention arrives. That's where your EDC Tourniquet comes along.


  Extremity (Arm or Leg) bleeding is the number one preventable cause of death in Trauma Situations, which means this situation is not to be taken lightly. A tourniquet applied properly may save a life in this instance. It's better to use one,  than hesitate and risk exsanguination or "bleeding out." The days of "Don't put it on or you'll lose that limb" are over, studies show that it will take 4-6 hours before permanent damage even begins.  Whether 911 is coming in 15 minutes or you are in an austere situation where help may be delayed or you may have to self-transport, none of that matters if they don't make it through these next few minutes. The decision is clear: Acting now or bleed out on the spot.   That's why I recommend a tourniquet being added to your EDC. Even if you don't carry a firearm daily, Medical injuries are far more likely in an emergency or austere environment than having to draw a firearm. That is why we're going to go over how to use a tourniquet and how to store them. We've already established types of tourniquets so you may make an educated purchase in another guide: Crisis Application Group: C.A.T's eat R.A.T's: Tourniquet Comparisons (CLICK HERE)

Self Aid is a critical skill
Self Aid is a critical skill  

If you can visualize a hole leaking water from a watering hose as the arterial bleeding and the faucet the hose is attached to as the victim's heart, you can know "Why" you're doing it:  the application of the tourniquet is basically you going farther up the hose (artery) to stop water (blood) from coming out. You may waste precious seconds with bandages and direct pressure hoping that fixes the wound. While those methods may be used to slow bleeding, you are going for arterial occlusion meaning the bright red bleeding stops.  "Twist, Twist, Twist the Windlass till the bright red bleeding stops." "Where do I put this thing?"   The CAT and SOFT-T only seem bulky but with a little folding you can make it's silhouette smaller. Personally, I carry at CAT tourniquet on me everywhere I go, and have at least 2 more in the car at all times. That's not even mentioning my medical supplies.

Buy the Combat Application Tourniquet (CAT)

A1   I recommend putting it on your belt, however this is not gospel and your imagination is the limit; You can use pockets, ankle holsters or truly conceal it under a shirt by looping it like a bandolier. With the belt method, you can loop the tourniquet through the belt as shown, using the velcro to your advantage.

  If you're worried about a tourniquet attracting attention on a belt, you can pull a shirt or jacket over it, just as with a pistol but with less chance and worry of imprinting. If you can't get it stable enough, try using thick rubber bands to tie it into the belt. If you still can't get it working or need a more durable container for extended wear and abuse, there are a variety of tourniquet holders that are commercially available that are smooth and keep it in good condition.




CAT's eat RAT's: Tourniquet Comparisons

We have come a long way in trauma medicine since the days of "Use a tourniquet only as a last resort." We now know it can be on for hours before it even begin to damage the patient, and now tourniquets are often times your first intervention in tactical medicine

A Guide to avoid gimmicks in the world of Tactical and Austere Medicine:

Tourniquet+poster   We have come a long way in trauma medicine since the days of "Use a tourniquet only as a last resort." We now know it can be on for hours before it even begin to damage the patient, and now tourniquets are often times your first intervention in tactical medicine. It's now a rush to create the latest greatest equipment, especially tourniquets, to save lives both on the battlefield and here back home as referenced in their success in the Boston Bombing. Most often times these new medical innovations are not created by a scientist in some dark lab but the warriors who return from the battlefield and realize what we need. I applaud those who innovate in order to save lives and experienced Tactical Medics can make their own decisions about the newest medical interventions. Unfortunately, some products

come out seeming to be best thing since sliced bread and we here at Crisis Application Group are here to help you make an educated decision in what you choose to purchase because this purchase may be used to save somebody's life.  Every tourniquet has its Pro's and Con's that can and should be mitigated by rigorous training. When the human factor is eliminated as best it can through rigorous training, THEN we can talk about proper equipment.  It doesn't matter if you have the best tourniquet in the market if you can't use it properly.



R.A.T. Tourniquet:

CATSeatRATS   Cutting right to the chase: I'm not sold on the R.A.T. Tourniquet just yet. (Pictured:) it has "TCCC" approved on it, which is not the military's official "CoTCCC" which Crisis Application Group's CEO was formerly a member of. That could be misleading to many folks that think it has been approved for battlefield use. The RAT tourniquet is a flat bungee that works through wrapping the cord around the extremity to stop bleeding. While you could improvise many items to slow the bleeding, I expect total arterial occlusion from a commercial product. I have yet to see Doppler prove that it occluded arterial blood flow, studies on live tissue, or real CoTCCC approval. The RAT tourniquet page has video documenting it stopping the pulse through the use of a Pulse Oximeter, but that is not where the bar is set. I see the temptation with the lower cost and size, but in medicine you can't take the "idea" over proven effectiveness. In the game of saving a life, you may have to spend the extra dollar.

CAG Tier 1 Med Packs! Complete modular systems $99!

  There is also the argument about proper width, which is directly correlated to soft tissue damage and more importantly arterial occlusion. It states and is 1.5" when properly applied, which I will give them the benefit of the doubt. However, with items used in a high stress environment, you'll want a redundant product that is less likely to be messed up. For instance, if there is too much spacing between the wraps, or overlapping too much could require the Operator to re-do the intervention, releasing the tourniquets pressure. In addition, Some haFlatBungeeTourniquetve argued about the length of RAT tourniquet on a thigh, but after seeing a video demonstrates it's use on a 26" thigh properly, I have no complaints there.

  A large portion of the reviews say it's fast enough than taking an already 'looped' CAT from the foot of the patient and jostling it all the way up. I teach my TCCC students the option for a CAT to instead be applied through the friction adapter at the correct height of the limb. This requires less movement and going around the limb than the multiple loops of the RAT.   A tourniquet isn't just about putting one on, but keeping it on. I would like to see how it would hold up in casualty drags and carries, where rocks, debris and gear can cause a tourniquet to possible become loose and therefore less effective.   If we received one in the mail, we'd surely test it out further. Until then, we'll wait till we see more concrete proof.

SWAT-T Tourniquet:

[caption id="attachment_454" align="alignleft" width="372"]SWAT Tourniquet SWAT Tourniquet[/caption]

   This is the SWAT-Tourniquet. It's name is also how to use it: "Stretch, Wrap and Tuck." . It's an elastic wrap, I've used one in practice when I came across it. It was very strenuous to get working and after application to the legs and I put it on aggressive and tight. In addition, when finished wrapping, you have to find a place to tuck the tail into or it will unwrap itself, which was one of the largest issues I had. I would mention the pain, but that has no room in saving a life because "The Operator feels no pain (when doing medical interventions.)"  I would not recommend this product that is not CoTCCC approved and many units do not allow it. I wouldn't even use it as a pressure dressing to avoid compartment syndrome, and an ACE wrap is easier to see blood leaking through if your intervention fails.

Committee of TCCC (CoTCCC) Approved Tourniquets:

  The two tourniquets widely used in the the Special Operations community as well as experience in the staff here at C.A.G.,  but even more importantly have approval from the Committee on TCCC (CoTCCC) and Fort Sam Houston's Institute of Surgical Research are the Combat Application Tourniquet, version 3 -or- CAT3 and Special Operations Forces Tactical Tourniquet -or- SOFT-T/SOF-T. CATTrauma CAT-T   The CAT3 has been ol' faithful for quite some time. It does get a lot of hate, though, and as someone who has taught all different groups of people TCCC, I can see where it frustrates newcomers. Just like many other good pieces of equipment, a tourniquet is not a learn-once and done. The CAT3 needs some practice to get down smoothly, especially with the friction adapter. C.A.G. has a video you can watch to learn how to do it right and practice in order to stay under the goal time of 30 seconds.

** A CAT3 once used for training or any other purpose should not be used in trauma.


SOFT-T:   Special Operations Forces - Tourniquet is another tourniquet we recommend, but just as with the CAT, it will take practice to get it right. If you foresee you or others in your group having a hassle with the tightness of the screw or remembering it, the newest generation SOFT-T has a buckle that makes life easier. SOFT-TSOFT-TW (Wide version with Buckle instead of screw.) LEFT: SOFT-T RIGHT: Newer SOFT-TW Wide with Buckle in place of the screw.




Improvised Tourniquets: token1

  Improvised Tourniquets are as their name implies, using what you have available in an attempt to create a tourniquet effect. They are good to know how to make and have prepared for an austere or mass casualty incident where you do not have one, or do not have enough tourniquets. However, they do not work as well as commercially designed tourniquets, so prepare a few in case you run out and tuck it away in your intellectual equity toolbox. Our very own Crisis Application Group's Jay Paisley demonstrates just how simple it can be.


  What I hope you take away from this article is to be skeptical of new inventions proclaiming to be the next big thing, especially in the business of saving lives. I could go over every possible tourniquet on the market and write a book but I'm sure you got the point. When you come across one you're unsure about, do some research or even feel free to ask us about it. Inspect your tourniquets as you receive them, as some have cheap after-market knock offs made of cheaper, flimsy products or even an older generation of what's currently best. I also recommend you take your tourniquets out of the packaging and prepare them properly as fumbling around with that can cost a few extra seconds when the goal is preserving "fresh clean blood."

CAG Class: Intro to Austere Field Medicine, Conyers, GA!

  Once more, I applaud those out there creating these products to save lives on the battlefield, Law Enforcement Officers and even Civilians back home. I would love for a product that is smaller, faster and lighter than what we currently use, but more importantly I want one that can save more lives. It would be a safe bet to stand back and monitor a product you're interested in while it receives further testing and real world application to work out the kinks. Even the beloved Combat Gauze had criticism when it first came out and replaced Celox and Chitogauze awhile back, then in the new TCCC updates Celox/Chito are back in the game as alternate uses because they work intrinsic of the clotting cascade and may perform better for someone with poor clotting factors. It goes to show you that what you knew about medicine 6 months ago may not be correct, and what you knew a decade ago might not work as well as what is out today.   For now I recommend you stick with what you know and keep training. No matter which tourniquet you or your community purchase, buy at least two; One for training, one to keep when you need it. Mark/spray paint the training TQ to keep it separate and train on it often to stay fresh and keep your time under 30 seconds. The equipment doesn't live up to its full potential without proper, consistent training.   If you have any question on medical products, feel free to ask the medical subject matter experts here at Crisis Application Group about it. We have Special Operations, Special Forces, former CoTCCC members and other Medical Professionals that can give you a professional opinion. Trust the reviews of those who have used tourniquets on real life trauma casualties. [caption id="attachment_2" align="aligncenter" width="300"]Med training with Crisis Application Group Med training with Crisis Application Group[/caption]   Don't take our word for it, Check out these References and come to your own conclusion, or Google "TCCC" or "CoTCCC tourniquets" : JSOM TCCC References: TCCC PDF from U.S. Army Institute of Surgical Research updates, as of 02 June 2014:




Austere management of Lower Back Pain (LBP)


Austere management of Lower Back Pain:

    Lower Back Pain can be difficult to treat, even with the luxuries of modern medicine. In an austere environment, proper diagnosis and treatment can prevent further injury and start the slow process back to recovery so you can get one of your fellow Emergency Action Members back on their feet. This is a quick little introduction that barely scrapes the surface, and is not to be taken as gospel. Acute Lower Back Pain (LBP) has many causes, one of the most common is from improper form while lifting an object. I see it in day to day life from Deadlifting when form gets sloppy as higher weight is attempted while the athlete is tired.  It does not need to be heavy weight at all as I've also had patients pick up a very light object  at the wrong angle and were in a great deal of pain. This is why good form is important.
     Back Pain, unfortunately, is not always an easy fix and definitely not a quick fix. Some have more chronic issues from herniations, disc degeneration, spondylosis/sponylolisthesis, and more that are much more difficult to fix. Others are caused over time from weak hip flexors, abductors or other muscular imbalances. It can even be caused from lots of high impact, especially if you have the wrong footwear or a Bug Out Bag on your back. These can all take us out of the fight, if at least for awhile.
  Before I get into treatments, I'm going to address the patient. With musculoskeletal issues, there is no magic pill that makes it go away and there is a lot of responsibility on the patients part. In my experience, I see many patients who do one of two things:
A.)   Fight through it and exacerbate the injury.
B.)   Baby it too much and it gets locked up and tight.
  Pushing through the pain because of your ego does not give it a chance to heal and babying it does not build it back up to help it heal properly. The correct answer is a happy medium, or as I like to call "Active Rest." This means resting at first, but not taking it too easy. Walking around if tolerated, stretching and foam rolling. This will help the healing process along. From there, progressively move in the right direction. It does not stop there, as there are many things you can do for a Lower Back Injury.

Treatment options to consider:

  • How to warm up and apply a heat compress in your situation.  (Heating up a towel)
  • Which medications, if any, to stockpile.  ( Muscle relaxers or pain management )
  • Herbal Remedies that work for you or patient. ( Some are a hit and a miss. )
  • Stretching, Foam Rolling, Massage ( work to regain full Range of Motion )
  • Physical Exercises to rebuild and strengthen core and supporting structures

It won't be easy, it won't be overnight, and you may not get back to perfect, but I guarantee you that failure to take care of yourself will only make it worse. Once an injury happens the first time, the second time can be twice as easy. I would recommend for anyone with LBP, as well as the Medic of an Emergency Action Group or other [caption id="attachment_1442" align="alignright" width="235"]( Just a few examples of some of the back exercises a physical therapist or other medical provider may show you) ( Just a few examples of some of the back exercises )[/caption] prepper group to have multiple reference books/guides/pamphlets. This includes finding out what pre-existing conditions/injuries you have in your group.If you prep food and water to prepare for eating or drinking, you should prepare your body for the rigorous labor of a survival situation or even the daily life of self sufficiency. Before an Austere situation, Physical Therapy can do much more for an injury than self care. Physical therapy regiments done consistently and properly can hopefully alleviate pain and have you moving in the right direction, but at a minimum prevent your LBP from getting worse. One of the books I recommend is the Treat Your Own Back book by "Robin Mackenzie." It doesn't end there, You'll want other books for the myriad of other musculoskeletal problems you may encounter, or that already exist in your circle. Finally, if you can remember one thing from this article ( Print it out and share it), Here's a couple red flags during a collapse to immediately seek higher medical care:

  1.  The patient complains of "saddle paresthesia" or numbness/tingling where a saddle would touch their legs if they were on a horse. (Makes it easy to remember)
  2. The Patient complains they have lost bowel/bladder control. This can be inability to hold it in and extend to unable to void bowels or bladder as well.

End note: I would like to ask you to comment with which methods of treatment, especially natural remedies have you used to manage yours or others? (There is no right or wrong answer, as different strokes works for different folks. )


" Ready - Sure -Secure "

Where are the Doctors?

The Scary Reality of Casualty Evacuation to a higher level of care:

You see it on Medical Survival and S.H.T.F. blogs often; Preppers with little to no medical knowledge or experience asking how to cut holes in peoples necks to breathe for them, push antibiotics and intravenous fluids they don't know about, and throw in a chest tube by cutting a hole in their thoracic cavity. What if a wrong intervention is performed, or the right one but the wrong time and now the patient is worse? Would you want someone who has never done that

before to do it to you? In a life or death situation during a collapse, you may say yes as a last ditch effort. I'm not writing about not learning medical interventions as I love teaching medicine, and am one of the instructors for CAG. I'm going to explain why we should first consider alternate routes to give our patients the best chance that you could give them. Those routes are having a dedicated medical professional in the group as well as having a plan to get them to the nearest medical professional, whether that is a hospital, medical tent, volunteer center or a friendly Doc you've networked with down the road.

Acquiring a Dedicated Medical Professional:

I will start off this section by saying that I don't think medical people are capable of something you are not... as long as you have the training. keep-calm-i-m-almost-a-doctor-14That being said, finding a like minded medical provider could be difficult to get started, but infinitely worth the rewards. While having a full-blown Doctor or Special Forces Medic would be optimal, don't discount a Nurse, Paramedic, or even specialties like Dental Tech. A Medical Professional is not measured solely by their title but in my opinion by their passion and willingness to learn in order to remain competent.  Having a Doc will be able to help you in a situation where medical care is not available, but if they like to teach and you are eager to learn, they will more importantly cross-train the group so you can all be "mini-medics", much akin to the Tactical Combat Casualty Care (TCCC) program where Medics train ALL their non-medical platoon mates on what to do if they are not around or get hurt. An added bonus, is if the region you are in is unstable for long enough, the medical professional in your group could provide services to other locals for bartering, depending on their skill level. If it is a natural disaster, you could assist them in volunteering to help the affected area while learning along the way. Simply put, a dedicated Doc can provide more in-depth medical care by not just knowing "How To", but know "Why." You can be taught to treat a thousand wounds, but if you come across a wound you've never encountered, you won't be able to manage it unless you know how and why the anatomy, injury and intervention work. That is critical thinking.

"We simply can't find a Medical Provider"

Finding a "prepper" minded medical professional before-hand is an ongoing process... So why not become one? I recommend to everyone, preparedness minded or not, (especially if they have children) to take a First Aid/CPR class. Inexpensive, Quick, Simple and a good way to get your foot in the door. Not only will this let you know if medicine could be your forte or your kryptonite, but you can benefit more than just your group through what you have learned. m49140188_adult-first-aid-cpr-aed-classroom-550x324CPR/First Aid looks good on a resume before an emergency and could come up in day to day life. From that entry level you could go on to CNA, EMT,  or even volunteer with your local firefighters to work first hand with paramedics and those who handle wounded individuals often. From First Responders you can see how calm you should act in a medical situation and grow from that, while helping the community and making friends you could possibly turn into fellow Emergency Action Group members down the road.

I've treated the casualty to the best of my abilities...but 911 is simply not coming:

This is one of the most commonly neglected areas of most preppers medical plans. I see that they want to learn interventions far above their skill set because a Doctor is never coming... Wait, Come again? Where did all these Doctors go, did they get raptured away and disappear out of thin air? My point is: There will always be medical pro's. Just because finances, governments, resources, electricity and all else collapses, they won't disappear. There have been Doctors who operated without electricity since the olden days, that knowledge won't simply dissipate. Even in Katrina there were volunteer tents and triage centers when the Hospitals were overloaded or non-operational. It would have to be a very specific situation for there to be 0% chance for your patient to see the next echelon of care. The truth can be much more difficult, but the chaos of it can be managed by training: Medical Evacuation. Set a P.A.C.E. Plan (Primary, Alternate,Contingency, Emergency), Which is a fancy acronym meaning, "If Plan A Fails, Go to Plan B. If B Fails, Go to C, etc." You'll need to designate vehicles such as trucks, quads or even that tractor-trailer, to having to walk with a litter or SKEDCO dragging them behind you. Make sure to also ration and set aside fuel only to be used for hospital trips. Know where the nearest hospitals are, their type, your route to get there and every different way route with maps. The distance to your regions medical facilities matter so you can plan how long it takes with different methods to get there, xx minutes by car, xx minutes by ATV, and xx minutes by foot, for example. After that has been loosely calculated, you can road trip there with your group for a get together.If you were to have a member of your group get severely injured, how many of your group will escort him? How many will stay back to manage the property? How do you communicate if the towers are down?  Which vehicle stays, which goes? When do you expect them back if you don't have communications/radio? This possible logistics nightmare are all to be planned and walked through in a rehearsal. This is also where you make strip maps. You may know where the nearest hospital is and scoff at this paragraph but I ask you to ponder if you are the one that is injured and someone else is unfamiliar, a major road is closed or blocked by traffic, weather or debris, or you show up and the hospital is over run with a mass casualty. you may have a problem. Finally, knowing whether a hospital is a level 1 or 3, A Pediatric hospital or a volunteer clinic set up after a catastrophe can make sure your time is best utilized making sure your patient has the best chance you can get. This is a good habit to establish even if you have yet to join an Emergency Action Group, or moved to a new place. Additionally, How do you prove you can receive medical care, or can pay for it? You'll want to bring what you'll need to receive medical care, and more. If you can prove you have medical insurance and cash, that may work. If the grid and financial low is far beyond that leisure, make sure to bring what you will need to barter for this medical care. Gold, Food, or others measures. This can be set aside with the emergency fuel explicitly to be used only for the Casualties evacuation. In summary, You can see how a casualty can be a culmination of all a preppers skills and resources. You'll need to put your first aid skills to the test, stay calm to recognize if he needs more medical attention or not when you fall back on prior training during a moment of stress. You will execute a plan and three more back up plans with maps to get him or her on their way to someone who knows more medicine and account for setbacks. You may need to barter for care while you are there and use your communication set up to communicate back to your main location if you will have an extended stay. Keep learning austere/survival medicine, but also continue to account for ways you can provide them quality treatment if needed.  I hope you gathered multiple thinking points to discuss with your Emergency Action Group. Most of these can be planned and talked over for the low cost of printed paper. I 100% believe in what Austere Medicine is capable of. A handful of years ago I was a young medic in charge of the medical care for dozens of men for the first time on a remote outpost that was over 100 miles away from the nearest medical center. If the weather was too poor for a Blackhawk helicopter to get off the ground, or they were busy evacuating trauma casualties in another region to divert assets, I was all that there was. I learned that while controlling hemorrhage is the cool meat and potatoes of trauma, I needed to learn all aspects of medicine and dive into books to truly take care of my peers. I've managed broken bones, heart attacks and other medical emergencies at a time where if I made the wrong call and underestimated it, my patient would die, but if I called a MEDEVAC for someone who did not need it, I would be taking up the resources from the battlefield that really needed it. I've taught these lessons to U.S. Regular Army and Special Operations soldiers, to NATO soldiers and local Afghan Military and Police forces. I impart these lessons I learned to you as well, in hopes you can better the medical readiness of your EAG.

LOGO PNGCrisis Application Group " Ready - Sure -Secure "

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