Recent involvement in investigations into industrial accidents and incidents involving security officers caused me to look into the state of first-aid training. I have some concerns that lessons-learned are not being applied as well as they should.
Recent wars have taught us how to teach personnel to control severe bleeding and maintain an airway under adverse situations. Unfortunately, from what I have seen, this hasn’t filtered down to industry in the form of better training and equipment.
This battlefield experience should be of interest security personnel at sites that might experience an active shooter or similarly catastrophic event. Those involved in emergency and business continuity planning should also take note of these lessons. My comments do not reflect the specific situation in any one Canadian province. I am aware of all the regulatory inertia, concerns about costs, and legal implications that inhibit change, but these are weak excuses for inaction when lives may be at risk. The injured person who is beading to death or suffocating doesn’t give a damn about laws and regulations–he simply does not want to die.
What’s an IFAK?
The Individual First Aid Kit (IFAK) evolved from US Army specifications for a first aid kit that provided essential medical equipment needed to address the two leading causes of death on the battlefield, severe hemorrhage and inadequate airway. These are also common causes of death in industrial accidents. An IFAK typically weighs about one pound and consists of expendable medical items packaged inside a durable pouch and mounted on the soldier’s load bearing equipment or body armor. Another term for the IFAK is a ‘blow-out kit’. I don’t know the origins of the later term.
Let’s look at the critical components of an IFAK.
Tourniquet
The recent unpleasantness in Iraq and Afghanistan taught us a lot about pre-hospital casualty care. For example, the return to using the tourniquet to staunch bleeding. The casualty care in recent wars has become so good that concerns about losing limbs because of delays in transportation has all but disappeared, on the other hand, it hasn’t become so good that the casualty can’t die from blood loss.
When I lived and worked in dangerous places, you had to write the time the tourniquet was applied on the casualty’s forehead in his own blood so that it could be loosened periodically (five minutes every half hour to prevent muscle and nerve damage due to compression). Back then, you were left to devise your own tourniquet with what was at hand and that usually meant surgical tubing that you hung from a shoulder strap of your load-bearing equipment. This worked, but it was too thin and could cause severe damage. The current trend is a tourniquet that is much wider and accompanied by a device to tighten it.
Addressed as an optional item in some first-aid training, and only in terms of using a triangle bandage as the tourniquet rather than a purpose-built product.
Israeli Bandage
The Israeli Bandage is a specially designed to stop bleeding from hemorrhagic wounds caused by traumatic injuries. First used during a NATO peacekeeping operation in Bosnia and Herzegovina, and subsequently adopted by many military organisations to replace the existing pressure bandages because it is a bandage that is almost as effective as a tourniquet in many cases. The U.S. military made it standard issue just in time for the Iraq War. Invented by Israeli military medic, Bernard Bar-Natan and manufactured in Lod, Israel, by First Care Products Ltd., these are real lifesavers. This bandage probably saved Gabrielle Giffords’ life in Tucson Arizona when the congresswoman was shot in the head in 2011. It’s particularly good at stanching head wounds, which is one of the greatest challenges with conventional bandages. The bandage applies a sterile pad to the wound to stop blood flow and the built-in applicator applies the equivalent of up to 30 pounds of pressure over the pad by wrapping it in the opposite direction of the initial wrap.
This is a superior product, but most first-aid trainers that I spoke to had never heard of it.
QuikClot
QuikClot® is an adsorbent hemostatic agent which rapidly stops blood loss in large wounds. The first generation of this stuff was brutal when applied, but it worked and saved lives. Today, it is in its third generation. It is now a gauze-based product impregnated with kaolin, which activates blood coagulation and minimizes the painful heat generation that plagued the first generation product. There are similar products on the market but this is the one familiar to me.
This has a good track record in combat and with civilian first-responders. This is for large wounds with severe bleeding. It stops the bleeding long enough for these injured victims to get to surgical care. It doesn’t repair the wound, it will eventually stop working, and when it’s removed, the bleeding will resume. If an artery is cut the limb is still at risk from lack of blood flow and Gangrene, just like the prolonged use of a tourniquet, but blood loss won’t kill the casualty.
Unfortunately, this is prohibited for use in first-aid kits because it is classed as a medicine or something with an expiry date.
Nasopharyngeal Airway
A nasopharyngeal airway or NPA is a tube designed to be inserted into the nasal passageway to secure or maintain an open airway. When a casualty becomes unconscious, the tongue falls back to obstruct the airway. The NPA flared end is to prevent the device from becoming lost inside the patient’s nose. . A sterile lubricant to aid its insertion should accompany this. These don’t trigger a patient’s gag reflex as often as an oropharyngeal airway and are easier for the less-trained individual to insert. Practice inserting this on a mannequin.
Nobody could clearly explain to me why this isn’t included in first-aid kits or why its use isn’t addressed in training. Most thought that it was a medical device and therefore not permitted in first-aid kits.
Chest Seal
Chest Seal is an occlusive dressing for penetrating chest wounds AKA the sucking chest wound that often happens when shot or stabbed in the chest. Properly applied, as the patient breathes in, the dressing is sucked over the wound and prevents air from entering; as he exhales, air will push the dressing off the chest and be able to escape.
This is addressed in some first-aid training but usually in terms of using an improvised occlusive dressing.
14g Chest Decompression Needle
This large-bore needle is inserted into the second intercostal space at the midclavicular line of the affected side to convert the tension pneumothorax into a simple open pneumothorax. This will let air escape the pleural space. Training is required for this, but recent wartime experience has shown that the training is easy to administer and that it is effective in application.
Unfortunately, it’s fine to teach soldiers this, but for civilians this is considered a complicated medical device and prohibited in first-aid kits.
Shears
These are necessary to gain access to wounds to apply bandages or a tourniquet.
Training & Equipment
I wish training and IFAK-type kits were standard issue with police, fire, and security personnel in Canada. Perhaps some Canadian organisation will take up the cause to improve the regulation and training in this area to apply the lessons learned from a decade of war.