Combatant Casualty Care - After Action Report
During February 4-5th, 2017, I had the chance to participate in the Combatant Casualty Care course run by Talon Defense and Ditch Medicine (and hosted by Sparrow Defense). As we've previously written about, Chase Jenkins of Talon Defense is an awesome instructor with his own style of instruction. This course coupled him with Hugh Coffee of Ditch Medicine. I have heard about Hugh from several people who have previously trained with him, so I was completely amped when the opportunity presented itself for me to train with both Chase and Hugh in the same course. Walking away from this course, I can say that both of these guys are truly a master of their perspective craft. Accompanying Hugh and Chase were three additional experts of their craft who we would enjoy the opportunity of learning from: , reigning national TacMed competition champion; Joseph "Jay" Paisley, former Green Beret and Delta Force Operator; and Chris Richards from Compression Works, LLC. (company that has revolutionized the Abdominal Aortic Junctional Tourniquet). Their input and expertise was an incredible asset to have with us throughout the training.
This was a two day course combining the skills necessary to both fight with handguns and as well as identify and fix traumatic injuries. As you're likely aware, I've done quite a bit of firearm training, specifically with handguns. This course would test all of the skills that I have acquired since I began training years ago, and would present new levels of stress and problems to test the limits of my skill set. Regarding the medical side of the house, the majority of my trauma medicine training has come from two different courses by Dark Angel Medical. After having taken this course, I'm very glad that I had previously taken the Dark Angel courses as the "academic aspects" of the traumatic training were not completely new to me. With that said, that's where my preparation for this course stopped. Unlike the firearm training, where I can handle most manipulations of the gun with minimal conscious thought- the medical aspects of this course were virtually all past my skillset. This forced me to focus on the mechanics of identifying and working through every little issue instead of being able to focus on the larger picture and be on autopilot for the multiple quick tasks that needed to be completed. To clarify, let's consider the following two examples:
- Double feed malfunction while unable to use your primary hand: No problem. If the "tap, rack, bang" method doesn't work, then I know to depress the magazine release, slam my left forearm down on an immobile object (usually my leg), rack the slide until clearing the obstruction, stowing the gun and retrieving a new mag, release the slide- and continue to fight.
- This is not an "easy task" by any stretch of the imagination, but it is a problem that I have worked through ad nauseum and therefore can go through each step with fairly low amount of mental exertion. This allows me to focus on the larger problems such as teammate position, movement of threats, etc.
- Self-Aid by applying a SOFT-T tourniquet to your own leg using only your support hand: I can walk you through each step, but even the description of the process requires me to actively think through each step.
- Though I can force myself through the process, it's not something that I have practiced enough to be able to do it on auto-pilot. My personal skill-set is simply not up to par in the medical portion of this course. This causes me to focus entirely on the task at hand which forces me to lose sight of the broader issues that require attention.
In short, there are likely other guys in this training who would have a very different perspective than me, simply because their experience level and skill sets might have been superior to mine in one or both aspects of the course. The following after-action report will obviously be from my own perspective, and merely provides some insight as to my experience in the course. It is also worth mentioning that I was the only participant in the course that is not an active Law Enforcement Officer, so the scenarios of the course as well as some of the exercises were specficially geared toward Law Enforcement.
After some usual briefings, we began with an introduction from Hugh regarding tourniquet placement, usage, and hemmorhage control. This began at 08:00, and it was 30o at the time time we started. Hugh, a small statured man weighing about 145 lbs, immediately strips his shoes off and rolls his pants up so that we can see the effects associated with having a full arterial occlusion through the use of a tourniquet. Furthermore, he left what would eventually become three tourniquets on his leg for the better part of 15 minutes so we could see the full effect. We also talked through some of the common misconceptions associated with the use of tourniquets, and how the last 15 years of war have revolutionized the use of tourniquets to save lives. The largest take-away from this section was that Hugh was an incredibly tough man who stood barefoot in the cold, wet grass of a freezing morning for almost a 45 minute period. I knew at this point that we were going to be physically dwarfed by a man almost twice my age and seemingly half my size. My presumptions were correct...
After working with Hugh through several different topics, it was time to get to the range so that Chase could rough us up a little bit. The vast majority of this course would simulate us fighting through some sort of injury, so it was only fitting that Chase take away some of our dexterity or mobility. With that said, Chase does a fantastic job at ensuring that we understand that the detrimental dogma that having an injury or tourniquet on us means that the effected appendage is out of the fight. This is not necessarily the case, and (as usual) the mental aspect of the training and the fight is all but the exclusive point of focus of Chase's instruction. We worked with a tennis ball in one hand to limit the use we had with that extremity. Chase would work us through drills that would force us to make decisions about positions, manipulations, shot placement, etc. In short, it was similar to a single-handed version of the drills outlined in our after-action report from the Dark Gunfighter course.
After my group's completion of the range exercise, it was time for us to head down to see "Uncle Hugh" (as he affectionately refers to himself). This would be our first encounter with Uncle Hugh's physical abilities. The guy is a machine. His cardio work is ridiculous, and his energy level seems to grow as he becomes more and more excited with the topics he is teaching. We began with some running and other cardio exercises to get our heart rates up. We went through an explanation of multiple variations of each piece of equipment, including variations of tourniquets, bandages, and chest seals. We went through the usage and application of each piece, along with the advantages and disadvantages of each variation. Hugh also went through an explanation of the triad of death, three stages of shock, and the effects that massive blood loss would have on the body and mind.
The next part of this segment of training was for us to partner up with someone. Each participant and their partner would spread out, one responsible for protecting the other. To simulate an altered state of consciousness, we would spin in a circle with our arms stretched out and heads tilted back until we were dizzy enough to literally fall down, our partners preventing us from running into any other participants. Once we had fallen down, the exercise was a timed event to get a tourniquet on our own right arm. This was to show us that even with a slightly altered level of consciousness that it is possible to work through the problem and provide self-aid. (Not only is it possible, it is imperative...) The next phase of this segment ended with cardio. Lots of cardio... The cardio was a relay race where we run approximately 50 yards, apply a tourniquet, back 50 and apply a bandage, back 50 and add another tourniquet, back 50 and another bandage, etc. The issue is, only one person is putting on a tourniquet/bandage at a time but everyone is running each leg of the race. Furthermore, each tourniquet had to be applied to full arterial occlusion. For those who are unfamiliar, that hurts. Furthermore, running on a leg that has a tourniquet is not just uncomfortable, but downright painful. The point of this exercise was to induce stress through physical exertion as well as make us understand that just because we have a tourniquet or injury does not mean that we are out of the fight. After the cardio was complete, we went with Uncle Hugh to discuss the application and maintenance of both vented and non-vented chest seals as a preventative measure to fight a sucking chest wound. Tension pneumothorax, or a "sucking chest wound," is 100% fatal if not treated. To make matters worse, they are almost guaranteed to occur in a patient who has a puncture wound to the thorasic cavity.
With this phase completed, we headed back to Chase for some more instruction on the fightin' side of the house. Having already worked with single hand manipulations of the firearm, now we would add in a level of complexity as Chase took us through positional changes. We would work standing, high kneel, low kneel, suppine, prone, and urban prone. These positions would become second nature to everyone but the manipulation of the firearm with proper muzzle awareness and trigger finger discipline would continue to demand our undivided attention. Chase showed us multiple ways to manipulate the gun in either hand from all of these positions, and then we burned through reps quickly and efficiently. Someone shot from the wrong position? Punishment. Chase loves to provide a negative stimulus if you aren't operating your body or your firearm in his prescribed manner.
Let's recap day 1... On the firearm side, we have now spent a great deal of time working shooting, manipulations, and malfunction correction with each hand individually. We have also worked on positional changes and how that impacts the way that we manipulate our firearm, particularly around other people. Our muzzle is our responsibility and none of us can use the excuse that we weren't aware and capable of safely manipulating our weapon with either hand from any position. On the medical side, we have spent ample time learning how to apply various types of tourniquets, bandage placement, shock evaluation, placement and maintenance of chest seals, and transport of an injured patient. Throughout the iterations of each training segment, we were physically and mentally drained and ready to recover and prepare for day 2. By now it's very clear: Day 2 is going to be a great deal of fun, tons of learning, and it's going to hurt.
When we arrived on scene for day 2, we kept our groups from the previous day. My group was paired up with Uncle Hugh, and the other group went with Chase. Out of respect of the instructors, as well as students who are going to take this course in the future, I'm going to purposely omit some pieces of various phases of Day 2. I feel that each instructor's content is theirs to distribute (not mine), and part of this evolution would be spoiled for future students if they knew more about what to expect. With that said, let's get started with our review of Uncle Hugh's first segment. Uncle Hugh ran us about 200 yards down to Jesson who was waiting on us with instruction to ensure that we were physically and mentally drained before leaving his station. This dude is quite the cardio-maniac, so this was easily accomplished. From here we were brought one at a time to a location of "sensory deprivation" which contained many elements of training which I will omit in this report. Just understand this, physical sensory deprivation, combined with fatigue, makes it very difficult to operate. This is real-world training, not classroom theory. This evolution was every bit as mentally challenging as it was physically challenging- and it left us all wide-eyed and smiling. Some fun ingredients to this element included: flashbangs, fog machine (to simulate smoke), theater blood (ample amounts), fire alarms, loud music, and other ways to deprive you of vital senses which would help you work through the situation at hand. Walking away from this evolution, I had a new understanding of the severity of the situation as well as how ill-prepared I am for a worst case scenario when one of my beloved is bleeding out. It leaves you humbled, but hungry...
With this evolution complete, our group moved over to Chase for more fun and adventure on the range. We picked up right where we left off on Day 1, but this time with partners. We worked barricades from positions of cover and all with one-handed manipulations. Chase was ever-present to induce malfunctions on your gun and force you to work your manipulations ad nauseum. From this drill forward, instead of working with partners we began working with entire teams. We would use everyone in our group and work through the barricades in multiple directions, forcing us to read one another's movement and work safely around the folks shooting at the same threats as us. In short, it was a combination of all of the skill sets practiced on Day 1, but with the additional complexity of having people all around you. Not only that, but both you and all of the other people would be moving around each other. This section is completely relevant to the way that we should fight with a partner or team for both maximum effectiveness and safety.
With both the initial medical and firearm evolutions complete, it was time to put it all together. The final evolution would be a scenario where we would have to use all of the skills that we had acquired up to this point and solve the problem operating as a team. This evolution was set to last approximately 30 minutes, though my group went went a little longer. Prior to getting underway, we were all "injured" by Chase as he chose which appendages we should be without. For instance, I had a simulated wound to my primary hand by Chase duct-taping a tennis ball into my hand and all of my fingers taped together and down on the ball. Other participants had other injuries, but we all had something wrong. After being taped up, we began the evolution with Hugh smoking us with some cardio. The man never gets tired. It's both humbling and humiliating. After delivering us back to the range, we were informed that we have an officer who was in foot pursuit through the woods and is now down with a gunshot wound. The condition of both the officer and the status of the offender are unknown. Our team spread out and searched the woods until we came upon our 200 lb dummy which represented our downed comrade. Having to utilize the abdominal junction tourniquet, multiple bandages and a chest seal, we had to make a litter in order to carry him out of the woods. Understand that all the while there is theater blood being sprayed into your face until you can achieve full arterial occlusion. "Distracting" is an understatement.
After stabilizing our patient and securing him on a makeshift litter, we had to transport. Each member of our team was assigned to either a carry position or security role, and we began our trek out of the woods. Upon arriving at a clearing, we had to lower the patient and double check all of our work, ensuring that the AJT had remained both secured in place and that full arterial occlusion was still achieved prior to pressing on. From here we were informed that the fight was on, and that we needed to get in it. Worn out from the trek through the woods, simulated injuries with every member having limited use of their appendages, we began moving to cover and engaging targets as they were called by our instructor. Each two members of the team had an instructor who would shout a position number and then a target number (or color) and we would have to work to that position of cover. All the while, we were working through induced malfunctions with one hand, helping teammates with gear or medical aid, providing cover while teammates reloaded, etc. Then we would feel the touch of a stick to an appendage followed by the shouts of an instructor that we had been impacted and we had 30 seconds to get a tourniquet on that appendage. Keep in mind that we are all operating with a single hand, so placing and securing a tourniquet would be all the more difficult without the use of both hands.
What happens if you engaged the wrong target or clearly missed your shot? Punishment. "If we're not working smart then we're going to have to work harder." This would be the introduction of additional malfunctions, smoke or other visual obstruction, the spraying of blood into your face, the tossing of dirt/rocks toward your weapon, etc. Work through your problems, and the problems will go away. One at a time, solve each little task prior to moving on to the next one. What's more important: the fight or the medicine? Well, when being shot at- the fight is a lot more important.
During the simulated fight, one of our team members was drug to the back of the range and I was informed that he had received a gunshot wound to the face. While holding direct pressure and a bandage to his face, I called for other team members to assist me. With some members still holding security, the others came and assisted in placing the wounded on a litter while also helping me secure the bandage so that I didn't have to hold direct pressure. The amount of simulated blood was surprisingly difficult to work through and seemingly accurate in its representation of a wound of that nature. (Note: our fallen team member weighed at least 290 lbs, so carrying him would be incredibly difficult. This was especially true since we were all working with one hand. Also note that no one on our team was surprised that our instructors chose the largest member of our team to be the one that required transport.) We were instructed to work as a team and get our fallen comrade to a place of extraction. It was not nearby. Once we arrived some 200 yards (through the woods) to the extraction point, we were informed that we had missed our helicopter evac opportunity and would have to evacuate by vehicle. They were not nearby. Taking turns pulling security and carrying our wounded, we went back another 100 yards and were told that each member of our team (including the wounded) had to be inside the vehicle prior to the evolution being over. Once we arrived at the vehicle, we somehow fit 6 members of our team into (or on to) a relatively small car and concluded the evolution. We were all completely spent. Still in tourniquets, still in duct tape, and covered in theater blood, we were right pleased to hear that we were finally through the final evolution.
Per my usual style, I will break this after-action report down into "The Good, The Bad, The Ugly."
Where to start?!? It's tough to isolate "the good" into a brief description when you have true masters of their perspective crafts providing you instruction. There was a ton of talent packed into this training session, both in the participants and in the instructors. The range facility is always great and the instruction from Chase was excellent as is to be expected. His casual and approachable demeanor makes him an incredibly effective instructor. He and Hugh work great together and have very similar styles of instruction. Hugh is very "up beat" and provides you positive feedback when you deserve it, and hammers you when you deserve correction. I feel like I learned months worth of work in a tiresome two day time period. Combine their skills with the addition of an industry leading manufacturer (Compression Works), the reigning national TacMed champion, and a former Delta Force operator/medic- and only a fool would complain about this level of instruction. Side note about "the good..." I have trained with a lot of police officers. I have shared the range with countless men and women in uniform. They are all great people, but as sad as it is to admit- I would say that the vast majority have no idea how unprepared they are to deal with violence in the real world. Too many of them shoot the qualification course (which is an absolute joke) and think that they are ready for a gunfight. This was not the case with the officers that I shared the range with during this class. While there was certainly variance in their skill levels both on the fighting side and the medical side, they were all "switched on" and prepared to face violence in the real world. It was refreshing to spend some quality training time with so many guys who really care about being able to protect themselves, their teammates, and the people in their communities that depend on them.
Slamming this much information into a two day course is like drinking from a fire hose. It's a lot to take in, no matter what your skill level is. As mentioned before, I felt much more comfortable on the guns than I did in the medical portions, so I would like to be able to have an opportunity to better prepare myself for that. While most people agree that running ammo down range is "more fun" than applying chest seals, I would venture to say that no one there was present just for the "fun" of the weekend. Don't get me wrong- we all had a fantastic time, but this wasn't a playground event. It might have been a positive modification to split us up for an extra evolution or two and allow those more familiar with the medicine to spend extra time on the range and vice versa. Another thought would be to spend one extra day in the course and add in the application and usage of NPAs, establishing and protecting airways, etc. Truth be told, I'm not sure my body would have held up to another day!
Soreness... The physical factor of this course was definitely enough to scare off any participant who wasn't absolutely certain that they wanted to be in this training. Going into the second day, we were all sore, tired, beat up, but eager to continue the training. By the end of the second day, we were all the worse off from increasingly physical evolutions. It was a great reminder that our physical strength and endurance is directly tied with our level of survivability, and that we should all spend more time in the gym. What my body could do routinely at 20 years old seems impossible at 33. To watch Uncle Hugh running circles around us reminded us all that we need to improve our physical conditioning.
If you're of the required skill level to be able to perform the tasks outlined above, then you'd be a fool to skip out on this course. It will highlight the areas where you need to improve like a white light. I would encourage everyone that is capable to take this training to better prepare themselves to prevail in a violent encounter and to potentially save the lives of those who need to be saved. In conclusion: I'd feel a whole lot better about you being on my side in a gun fight if you had completed this training course.