One of the challenges associated with tactical medicine is the lack of diagnostic equipment at the point of injury and throughout the evacuation process. The tactical situation can limit the ability to use exam lights (of any color) and post-engagement hearing loss or environmental noise can eliminate your ability to use a stethoscope or to hear at all.

It is important to practice different techniques for assessing your casualties’ status that do not require the use of diagnostic tools or one specific sense. Hearing is the most regularly affected sense in the combat environment and it is the sense medics rely on the most heavily. Large blasts or firing a weapon can cause a significant ringing or a muffle in your ears. Therefore, when listening for slight variations in breath sounds or a fading pulse, it can be next to impossible to hear. That is why you must learn alternate methods for assessing your casualties’ status.

One skill that is often affected is measuring blood pressure. If you don’t know how to take a palp. blood pressure or know how pulse presence roughly correlates to levels of BP, you need to learn and practice the techniques. They also come in handy when working in the back of a helicopter or loud vehicle such as a track-vehicle or Stryker that are on the move. Here are some examples of pulse pressures associated with the presence of a pulse in various locations.

Pulse Location/Correlating Pulse pressure

Dorsalis-pedis pulse/90
Tibialis-posterior pulse/90
Radial pulse/80
Femoral pulse/70
Carotid pulse/60

These are very rough estimates and should only be used when no other means of measuring pressure are available. Studies have shown that this method often causes medical personnel to overestimate their patients’ pressure. We suggest this method be used to note which pulses are palpable during the initial set of vitals. Mark the location of these pulses with a Sharpie® when they are found. If a pulse that was present becomes weaker or disappears as time elapses, your casualty may be deteriorating, and you need to do something to address the cause of that deterioration. As stated earlier, this method should not be used if an accurate pressure is required.

The inability to use the sense most suited for the evaluation of a casualty is not just limited to taking blood pressure. It affects your ability to assess a needle decompression in a helicopter, looking for unilateral rise and fall of the chest, feeling for injuries and many other portions of your assessment. Regular practice of alternate methods of assessment should be included in your training regimen, because it’s too late to practice after your ears are ringing from the IED blast.

Who is providing your training? Is it a company that manufactures or distributes products? If so, beware. We receive emails and calls weekly regarding training. We do not offer training, because it is difficult—perhaps impossible—to offer students quality training without conscious or unconscious biases impeding. Therefore, we recommend finding companies that do not have a vested interest in selling products. Finding quality training is difficult. Budget, geographical, and time constraints may limit your ability to receive quality TEMS/TCCC training. Unfortunately, factors beyond your control may force you to attend a class provided by a company that peddles their products behind a guise of training.

Below you will find a list of topics that ought to be covered by a training program, as well as telltales of product peddling.

1)Care Under Fire Phase techniques and considerations
2)Tactical Field Care Phase techniques and considerations
3)Patient evacuation methods, movement, equipment
–Litters (e.g., rigid, semi-rigid, pole-less)
–Rescue Tactics, which is the most important part, and equipment
–Hypothermia prevention/treatment
4)Hemorrhage control and treatments
–Tourniquets, Bandages, Gauze, Hemostatics how to use each
5)Airway/Breathing treatment techniques and considerations
–NPAs, Crics, occlusives, and needle decompression
6)Fracture ID/management/Splinting techniques and considerations
7)IV/IO techniques and considerations
8)Multiple Casualty/triage methods and documentation
9)Casualty model scenarios (live and simulated, the former being preferable)

Signs of product peddling: Instructors might display multiple products in one category (e.g., tourniquets) that you might see in your theater of operation. Next, they discuss the pros and the cons of each product. However, watch for the “cons” identified when discussing the product they sell. Instructors will highlight all the negatives of other products, often citing anecdotal cases or out-of-context research, while offering “vanilla” cons, if any at all, for their product.

That said, test products after learning their proper implementation in a course. Instructors do not hold a monopoly when it comes to knowledge. They may be basing their “facts” on assumptions, one poor experience or hearsay. Test items yourself. Call the company that provides products and ask the benefit of its product. Gauze, for example, is gauze. Therefore, if a company tries to tell you it has the best, question its judgment.

In the end, you ought to seek the best training and the best equipment, because yours is a business that saves lives. Do not become enamored with a company’s products because they provided training. Furthermore, because a national organization approves a course, product, or methodology do not assume it is best.

Here are a few US companies, with which we have no affiliation, that offer training and do not push products:

JTM Training Group
http://www.jtmlasvegas.com/

Mobile Asset Security and Training Group
(http://www.mastsolutions.com/training.html)

Teir 1 Group
(http://www.t1g.com/)