31 Oct 03

In 2004, my good friend and colleague, Dr Tony Barrera, and I are scheduling several one-day Treatment of Gunshot Wounds courses. The first will be in Memphis, TN on 1 Mar 04. This is a critical subject, at "treatment under fire" is often not addressed. Anyone interested contact me directly at jsfarnam@aol.com.

I've included below our entire 2004 schedule (so far). Again, contact me directly for details.

/John

31 Oct 03

I forgot to include one course:

7-9 May 04 Basic/Intermediate Defensive Handgun, Midvale. OH

/John

31 Oct 03 More sage comments from another physician who is a friend and student: "One of the points I try to make to people trying to keep someone (maybe themselves) from bleeding to death is, as you say, direct pressure on the bl eeding area. We're talking about major, arterial bleeding here. Bleeding other places (muscle, skin, etc) is certainly wet and messy, but not immediately l ife threatening. Besides, the fight may still be ongoing, and you will thus hav e more important things about which to worry! For bleeding arteries, many like to think of a tourniquet. It is usually a poor choice. However, once applied, it stays undisturbed until arrival at t he OR or (at least) the ER. None of this BS about 'loosen it every ten minutes to allow blood flow to the extremity below the tourniquet.' The third time y ou loosen it, it will be a moot point, because there won't be any more movement of blood. When blood isn't moving, it does what it is designed to do: clot. By applying a tourniquet, you have made the decision to sacrifice the limb distal to it. At least you should believe that's what you're doing. Far better that you stick your hand directly into the wound and feel for the major pumper. Each spurt feels like a 'buzz.' Then, follow that se nsation, until pushing somewhere makes the buzz stop. And, if your hand is covered w ith moose shit at the time? So what! Get to the task immediately. We're talking about saving a life here. Don't worry about germs. He surely won't die of infection during the next ten minutes, and, after all, we do live in the 'age of antibiotics.' Infection we can worry about later, much later. The advantage to this kind of direct, digital pressure on the buzzing artery is that the surrounding, uninjured vessels will then do what that deadly ' loosen-it-every-ten-minutes' technique is supposed to do, ie: provide a cont inuous (albeit marginal) moving blood supply to the limb distal (downstream) to the injury. As long as blood doesn't become stagnant and subsequently clot in t he vessels, the distal portion of the limb will be fine. Applying, for example , a tourniquet around the neck in an effort to deal with a severed carotid artery would be absurd . Instead, you feel for that carotid injury and push on it, and you get to stay that way all the way to the hospital, even if it's s ix hours away. My brother-in-law, a gentle internist and one-time ice-dancer, once found himself on the scene of a skating accident in which the back end of a skate blade passed behind the collar bone of another skater during a collision and injured the subclavian artery. It produced a one-inch laceration, but Ray c ould do nothing to stop the bleeding. The kid was DRT within a minute. Now, would I, as a hotshot surgeon, have whipped out my trusty Cold Steel, slashed open th e kid's chest, shoved a hand in, and controlled that huge vessel? Not bloody likely, I'm ashamed to say. I think only a heroic, practicing thoracic surg eon might have tried it. And, once the hand is on the artery, what are we going to do about the rapidly developing tension pneumothorax that's also going to kill this kid if the bleeding doesn't kill him first?" Lesson: Farnam's First Rule of Tactics: Do the best you can. We teach sound doctrine and techniques, but we're not going to "win" every gunfight, and we're not going to save every life. We're warriors, and we go forward boldl y, but this life offers no guarantees. Tourniquets are appropriate mostly in cases of traumatic amputation, where all you are presented with is a stump, as the distal portion of the limb is toast anyway. The pressure technique described above is superior in most ot her cases of arterial bleeding, and it is the one to which we should default. Keep in mind that all this will probably have to be done during or shortly after the gunfight. No matter how severe the injury to yourself and/or othe rs, the source(s) of danger still must be neutralized as quickly as possible. /John