Dirt Medicine - The Basics
On the side of the highway. In the middle of the forest. Out in the desert. In the kitchen, the backyard or the playground. This is where dirt medicine takes place. It is not based on clinical environments or textbook theories, it is based on the real-world application of life saving techniques and current best practices. Who is the true first responder in an emergency? You are – or whoever else is on site whenthe need for dirt medicine arises.
The first part of good dirt medicine is a proper assessment – assessment of both the situation and the patient. Concerning the situation, you need to make sure that you are not about to become part of the problem. In other words, if there’s a threat, eliminate it. If there’s a hazard, avoid it or wait for it to pass. You can’t help anyone if you are down and out. Next is patient assessment, and a good assessment isvital to higher survival rates. What can you see from a distance that can tell you about what happened or what injuries there may be? As you approach someone who may have been injured, can you communicate with them or are they unresponsive? Are there visual signs of life threating injuries, such as massive bleeding or a lack of breathing? Are there obvious signs of what the cause of an injury is in the physical items around the injured person, or is the environment itself a potential cause? All of this will get you started in the right direction with your assessment. Remember that in dirt medicine, you are the first and most important patient – fix yourself before trying to fix anyone else.
The second element of dirt medicine is M.A.R.C.H. It is an acronym that is easy to remember, simple to apply, and helps us to treat each potential life threat as we find it. We are always looking for what is going to kill our patient next. Keep in mind that you are potentially your own patient! There are a couple of primary goals in dirt medicine: 1) Keep oxygenated blood circulating through the brain; and 2) Get the patient to a higher level of care. This could be a larger medical kit, a paramedic or a trauma center. Now, let’s break M.A.R.C.H. down into its 5 parts.
M – Massive Hemorrhage: Is there any blood spurting, squirting, pooling or soaking? If so, stop the bleeding by applying a tourniquet high and tight, as close to the heart as possible. If a tourniquet can’t be applied, because the bleeding is in the neck, groin or armpit areas, or if a tourniquet is not immediately available, pack the wound with gauze until you are out of gauze or out of wound, and hold pressure until the bleeding stops. You may need to remove clothing in order to see if any massive hemorrhage is taking place under that clothing.
A – Airway: Is there an open airway? The tongue is the most common airway obstruction. Many people know the head tilt/chin lift method of opening an airway, and that is a great option. The jaw thrust, if you know how to do it, is a better option when possible head, neck or spinal injuries are present. Is there an obvious blockage of the airway? If so, remove it.
R – Respirations: is there active breathing happening? This is why we start with airway, to make sure we have an open path for air to travel. If there is a lack of breathing, or trouble breathing, repositioning can help a lot – sitting up, rolling onto the side, etc. Find out which position relieves any respiratory distress. If there is still distress, or if there are any obvious holes in the area between the neck and the belly, then put a sticker over the hole! Use an occlusive seal or a chest seal to prevent outside air from flowing into the chest cavity. If your patient is talking to you, ask them questions about who they are, when they are, where they are and what happened. Continue with questions that seem important to the situation, such as where it hurts, medical conditions, diabetes, the environment, etc. And if they are talking to you, then airway and respirations are good (for now). Count how many breaths per minute in order to get a base line.
C – Circulation: do they have a pulse and what other injuries are present? We need to check and make sure that a pulse is present, and if it is, what the pulse rate is. We can use this number as a baseline later to check for other injuries or to make sure we’ve properly handled the injuries that we worked on. If there is no pulse, then we need to begin chest compressions at a rate of 100 per minute. If an AED is available then we need to get that going, as well. If a good pulse is detected, there’s still no harm inhooking up an AED if it’s available or if you suspect any kind of cardiac emergency. This part of the assessment is where you will start addressing other wounds: broken bones, minor bleeding, burns, environmental injuries, etc.
H – Hypothermia: prevent and treat shock. There are different types of shock, and different stages of shock, but in dirt medicine all shock is essentially treated the same: maintain body core temperature (98.6 F), keep them still, and monitor (go over M.A.R.C.H. again!). Most injuries will lead to heat loss (hypothermia) rather than heat gain (hyperthermia), however you also want to consider the environment that the patient is in when considering how to maintain body core temp. Covering them up may help to keep heat in, but not as much if they are laying on the cold ground. Giving them shade in a heat stroke situation may prevent direct heat exposure, but not as much if they are laying on the concrete during a 115 degree day.
Now that we’ve discussed the fundamentals of M.A.R.C.H., let’s take a look at some basic tools that you can carry to help you during this life saving process. First of all we have to remember that skills will always trump tools, and tools are nearly useless without skills, but skills and tools together sure make the job much easier. It is vital to make sure you have the appropriate training for whatever gear you are going to carry around. Based on the experiences of our instructors, there are 5 essential components that should be considered necessary for any emergency trauma or dirt medicine kit.
5) Occlusive Seal
How much or how little you spend on acquiring those 5 essential components is really up to you and the type of kit you are building, just make sure you buy from a reputable distributor, such as the pre-made kits from The Well Armed Woman or individual supplies from The Tactical Medic. Buying from eBay or other online market sites can leave you open to unknowingly purchasing replica items, cheap knockoffs or old equipment, all of which may fail you when you need it most. There are certainly more things that you want to put into a trauma kit, based on individual situations and training levels, though the 5 essentials as we’ve listed them should be the basis for any good kit. If we were going to add 5 more, we’d go with nitrile gloves, trauma shears, emergency blanket, more gauze, and a hemostatic gauze, such as Celox or Quikclot.
As already mentioned, if you don’t train with your gear then it won’t be of much use to you. Make sure you train with a reputable instructional organization that is teaching dirt medicine concepts based on their experiences and current best practices. In other words, clinical and textbook medicine are very useful things in the world but someone whose experiences are based primarily in those environments is not someone I want to learn from when I’m trying to figure out how things work in the rain, at night, when it’s 20 degrees outside. Once you have the solid training, practice is what makes permanent. Begin incorporating basic medical exercises into your daily, weekly or monthly training regimen. Be sure you practice those techniques in the dark, in the cold, in the heat, in the rain, while wearing gloves, and so on – not just when it’s comfortable for you! Share your information with anyone who will listen – we learn best by doing and you don’t truly know it if you can’t teach it! The more we can get this information out into the world, the better off we will all be.
Glen Stilson - Owner – Independence Training
Adal Lopez - Lead Medical Instructor – Independence Training