Combat Life Saver

American medicine is the greatest in the world, and nowhere is that more evident than the combat casualty numbers from Iraq. At the current rate, America would have to stay in Iraq for 80 YEARS to catch up to the deaths from Vietnam. Of course, comparing the wars is ludicrous, because the level of combat in Iraq is nothing like what we saw in Vietnam.

Even so, part of the explanation for the low number of deaths is the amazing care our soldiers get – in the hospitals, and on the battlefield.

Consider this – of all of the wounded who are evacuated to a hospital, 90 percent survive their wounds. That is an incredible record.

Over there, there are only so many medics to go around, and often they can’t get to the patients in time. If a column of Humvees is hit by an IED (Improvised Explosive Device), you can’t always just stop and call for a medic. Often, the insurgent (or “Serge” as he is personified by the Army) will set up snipers and other IEDs to create a “kill zone.”

One of the best ways to get quick medical coverage – sometimes on the fly – is the presence of Combat Life Savers.

CLS’s – as they’re called – are not quite medics, but can do a lot of the basic lifesaving tasks quickly, which buys the patient crucial time. Time that often means the difference between life and death.

Among the tasks CLS’s perform is diagnosis of wounds, as well as initial treatment. Wounds treated by CLS’s include amputations, serious arterial bleeding, facial wounds and tension pneumothorax (a buildup of pressure inside the chest cavity often created by a chest wound. This last wound is dramatized in the movie “Three Kings” and is treated by shoving a very large needle and catheter into the person’s chest. It takes nerve to do, I’m sure, but the patient will die 100 percent of the time if it isn’t done.

I know all of this because I am now a fully-certified Combat Life Saver, a task I accomplished this week. To get this certification, I had several long days of classroom work, plus an amazingly intense day in the field.

We started out with a gory video of various wounds, including those inflicted on innocent Iraqis by insurgents as punishment for helping Americans. I will spare you the details.
We then went through the full gamut of battlefield health issues, from heat and cold weather injuries to amputations and sucking chest wounds. And then came the kicker – learning to give IVs…to live patients no less.

Our class – 50 people, mostly Air Force and Army, but five Navy – was broken into pairs. For this exercise, I chose Chief Huzy, one of my Navy buddies. After practicing numerous times on the dummies, we got to do the real thing – on each other.
To insert an IV into a patient, the following procedure must be followed:

1. Prepare your supplies. As a combat life saver, you will have a bag of goodies that you carry around. This bag should include two or three smaller packages of IV supplies pre-organized so that you’re ready to “stick” someone on short notice. Items you need, include:
a. 18 gauge IV catheter/needle set
b. Saline lock adapter plug
c. Constricting band
d. Tegaderm dressing
e. Alcohol pads
f. Sterile gloves
g. 21 gauge 1 1/4 inch needle (For flushing your saline lock, if needed)
h. IV bag
2. Prepare the IV bag with the appropriate fluid (usually a saline solution, but also a blood expander called Hextend can be used). Attach the IV tube to the IV bag, and then run out the fluid until it fills the whole tube.
3. If needed, fill up a syringe with fluid from the IV bag. This is used to flush your saline lock if the IV is to be delayed.
4. Select a vein. The best area for a CLS is in the inner area of the elbow, where the veins are large, exposed, accessible and best suited for treating in a difficult environment. Usually, you stick someone a couple of inches from the crease in your arm towards your hand. You want to avoid actual joints, or areas where a pulse is easily felt. Obviously, you do not put in your IV below or near an injury. Typically, if the right arm is injured, you stick the left arm.
5. Apply a constricting band. Everyone who’s had an IV done on them knows this trick. A big rubber band is tied tight around the arm about 2 inches above the IV site. This is like a mini-tourniquet. It slows down the blood flow to the arm, which exposes the veins a little more.
6. Put on your sterile gloves, and locate the vein again. Clean the site with a sterile pad.
7. Insert the catheter/needle. Go in about 30 degrees, pulling back on the skin as you do. At some point, you will get a “flash” of blood in a small chamber in the needle. That means you’ve hit the vein. Go in a bit more, then push the catheter (a small plastic sleeve that goes in around the needle itself) forward. Once the Catheter itself is in the vein, the needle is not necessary.
8. Remove the constricting band (unless you want this guy’s arm to go entirely numb).
9. Remove the needle, holding pressure above the vein, which presents…let’s just say it prevents a big mess from happening.
10. Screw the saline lock onto the catheter. Once you’ve done this, you can release pressure. The saline lock is like an airlock on a space ship. It prevents blood from flowing out of the vein, but gives you an entry point to add in your fluid. In a hospital setting, this step is sometimes skipped, because you’re going directly to an IV and don’t need it. In a combat situation, you may need to stop treating your patient and start shooting. Or, you may not need to give them fluids now (for a minor wound), but may want to put in an IV portal so that you’re ready to go when you do need to do that.
11. If you go directly to an IV, you can simply plug in the IV bag. Otherwise, you should flush the saline lock, which basically fills it with a small amount of saline fluid. The other thing this does is verify that your catheter is in the vein and not past it. If the latter is the case (which it was one time for me) the fluid will create a little bulge above the site of the needle and you have to star over. This is called “infiltration.” It can be a little uncomfortable for the patient, as it was for me.
12. If there is no infiltration, let the juice flow.

So, after only two days of classes – and maybe only three hours on the IV itself – two amateurs were about to stick needles in each other. Neither Chief Huzy nor myself were too afraid of getting stuck, but I think it’s safe to say we both had a little trepidation about sticking the other person.

Our CLS class was in an old movie theater on base. Almost all the buildings on Fort McCoy were temporary wooden buildings built for World War II, from the barracks buildings we live in to the church where I went to mass the one Sunday I had off. (As a side note, there are about a dozen chapel buildings, easily distinguished, across the base. All but two (one Catholic, one Protestant) are closed.)

Most of these buildings were built hastily – intended to last five years and no more. For the most part, they’re built identical to one of two or three patterns. In fact, I suspect that the army had them all built in Henry Ford/mass-production style at one single location, then had them assembled in place on the post.

The movie theater, therefore, looks like any other two-story barracks, with the exception of having no windows and no second floor. Inside, it’s all been changed around, but several of the wall panels have homemade cartoon-like artwork painted on them. They appear to illustrate scenes from a movie – or perhaps a play that the soldiers on base in WWII presented. I’m sure it dates from the war because of the style of the artwork and the clothing that the people wear.
One panel has a very ugly woman in a crown descending stairs inside what looks like a castle. Another has a similarly ugly woman dressed like a mermaid. They have names stenciled above them (the mermaid was “Rose” and I can’t remember the other). Their features look somewhat masculine, which leads me to believe it had to do with a play performed on Fort McCoy during the war, because (much like Shakespeare’s plays in the 1620s) almost all actors in military plays were men, and it was very common for the female parts to be played by men in drag.

So, getting back to my story, Chief Huzy and I followed one instructor – a combat medic with a couple of tours in Iraq behind him – into a back room and sat down at a completely un-sterile table. Of course, the battlefield isn’t sterile either, so this was a good simulation. And the equipment actually used is very sterile.

I volunteered to go first.

Starting with my right arm, the chief began his stick. Of course, he had to choose a vein next to a nerve. It was unpleasant, but I said nothing.

He never got the “flash” in the chamber, and had to pull the needle out. He tried two more times on my other arm. The first failed as well. The second was in the vein, and a lot of blood came out (he missed the step where you pinch off the arm above it (which I later missed on him). Nonetheless, that stick didn’t work either because of infiltration.

We then gave up on me (the chief would later stick the instructor, successfully), and I had my turn to stick the chief. With the exception of letting out some blood – I let him rib me about that so he didn’t feel bad about my own thirty-minute personal torture session that he put me through.

But this wasn’t the end of CLS. Neither was it the end the next day after we took our test. In fact, the real work only began after the test was done. The first thing to do was to learn more about treating a casualty in the field – from litter carries to Humvee extractions. After a half a day of those practical exercises, we moved back to FOB Freedom for Day Four of the class.
We broke up the class into teams of about 12 people. Ours had four Navy, four Army and the rest Air Force. We then went out on short combat “patrols” within the FOB.

The day we did this (Was it a Wednesday? They all seem to run together), the temperature had dropped from the 90s down to the 60s, and it began raining. But, as we had learned a few days before, the Army doesn’t stop work until there is lightening (that handy-dandy M-16 you carry around apparently makes a wonderful lightening rod). As they say, “If it ain’t raining, we ain’t training.”

So we organize in a wedge formation and start our patrol, heading to a point only about 200 meters away. Before we get there, of course, our instructor, who is behind us, pulls the pin on a flash-bang grenade and throws it to our side. A loud boom comes and he runs up to one of our guys and slaps him on his right arm.

“You’ve just been hit. Fall down and start screaming.”

The first thing we do, of course, is the right thing. We get cover, and aim our weapons in the direction of a supposed sniper. In wartime, you can’t sit there exposed to enemy fire and treat a patient. That will only create two dead people. If you’ve seen “Saving Private Ryan” and saw the scene where one of their soldiers goes down to a sniper in a French Village, you can see what I mean. The others couldn’t get to him until the sniper was dead – or distracted.

So we gave covering fire (not really fire, as we had no blanks for this exercise), and some of our team pulled the wounded man to cover using the handle (made for just this reason) on the back of his body armor.

Then, as the rain poured down, we proceeded to give him an IV right there in the rain, muck and mud. I didn’t see how it went, as I was protecting the right side (after grabbing the wounded man’s weapon, which we also don’t leave behind). But apparently it went well.

We returned to the center of the FOB and crouched inside a concrete bunker for another 30 minutes before our next scenario. In this one, I got to do a tension pneumothorax stick. Since you can’t do this on a live patient, we used a dummy, who just happened to be lying in the foxhole we pulled our next casualty into. So, as this next member of our team was being stuck with an IV needle, I was jamming a bigger needle into a standard issue Army dummy. (They all look the same – a white guy with brown hair – though for our IV practice, they had some arm-only dummies and one of the arms was black. Viva diversity!)

We did two more patrols and three more sticks. We ended the day by gathering all but a couple of us into a tent. The instructors then simulated a mass-casualty event. They gave us all little cards with grotesque clinical pictures of wounds. We were then told to scream “like you wanted an Oscar” and the other class members were then brought into this chaotic hell to triage and treat patients.

I didn’t have to get stuck with an IV (they weren’t doing this here), but I did get a tourniquet placed on. I wasn’t much into screaming, and since my wound was severe enough, I just lay there in the mud and took a little nap.

When I woke up, they handed out our certificates. I was now a certified Combat Life Saver, though I had to use my last water from my canteen to wash my hand clean of mud before I took the piece of paper.

It had been an exhausting day. I was completely soaked, my back ached from my body armor, and my M-16 was covered in mud. Arriving back at the barracks, I walked into the shower with my weapon and all my gear and turned on the hot water. Later on, I’d have to strip my weapon down and spend an hour cleaning it thoroughly, but for a few minutes, standing there in the welcome rain of steam, I felt at peace with the world.