A fundamental in battlefield medicine that's been passed down for decades has been "sealing the box". This is where we prevent any air from entering the chest cavity while making sure we can release any that's already trapped inside. Our magic tool we use for this,...the vented chest seal.
That tiny, rubbery, sticky dressing has been an essential part of every aid bag since it was introduced. Shoot, if you're old enough, you had to make the flutter valves yourself by leaving a corner of the dressing open. After years of data, though, what have we learned?
Just recently I had the honor of being trolled by a living legend in battlefield medicine. While most internet hecklers have little to no knowledge of the subject matter and a below average comprehension level, mine turned out to be the exact opposite. His name was Dr. Fisher and his accolades go far beyond mine, and probably yours too. He said something that roused up the chat mob and got me thinking about some of my very own experiences and I was surprised when looking back on them.
So, what was said that was so outrageous? Y'all, if you thought my position on quick clot and the Israeli dressing was blasphemous, then get ready. Sealing the box IS NOT a high reward procedure in combat medicine! Shit, I told you....blasphemous!
I know George Clooney and Mark Wahlberg taught us everything we need to know about sucking chest wounds in their quest for Kuwaiti bouyon, however, let's put down our pitch forks, step away from the rable and have a productive conversation. This statement actually got me thinking about some of my own "seal the box" incidents in Iraq and Afghanistan. Let me tell you two stories that are definitely not from a Hollywood movie. And no, that's not me in the photo up top, but, I do know those two handsome gentlemen.
Story A: "Lets go Smith! We're Loosing Him!"
My very first patient I ever treated in Iraq was pretty fucked up to say the least. I was riding along as a medic for a resupply convoy between Tikrit and another small base outside our AO. Most anyone who's done these long movements will tell you, it's not the ride out, but the ride back that gets interesting.
While headed back to Tikrit in our little eleven-fourteen, I got my very first call over the headset that actually meant something to me. "Doc! Hey, Smith! Hey, they got somebody shot up here! Hey, get ready buddy were gonna drive you up there." This was followed by "break, break, break. Medic, medic, medic."
When we pulled up to the scene I saw two vehicles in security positions with a HUGE horseshoe of individuals circled around something. After I hoped out and ran up to the scene, I could see they were almost all Iraqi Army personnel circled around one lone man stretched out flatter than a doormat and squinting from the sun beating down in his face. The second thing I noticed...none of them were helping him. Not one.
It didn't take long for me identify his injuries, but there was something more tense in the air than the smell of this guys body odor. Typically, when one of your teammates is wounded, you and the rest of the squad are in a frenzy to help. The medic usually has to push y'all back so he/she can do their job. Not only were none of his friends helping, they were all staring daggers at him. Not one finger was lifted for him before I got there.
Now's a good time to tell you about his wounds. He was shot multiple times in his torso. These weren't 7.62rounds, though, they were much, much smaller. I also didn't find a single exit wound. This is when I diverted my attention from my patient and noticed all the Iraqi Army personnel that were circled up around us all had Desert Storm era M16A2 riffles. Now, the plot thickened.
I looked at my senior medic, Chantilla, and detailed what I had. My higher ups made the decision we were going to back track it to the little base we just resupplied and get him to the PA as quick as possible. We littered this dude up in the back of an LMTV style vehicle we were using as an FLA and got in line of the convoy to start moving.
Hunched over in the back of this vehicle, we kept treating our patient. In full kit, sweating fucking bullets and in the hot back of the most not tactical vehicle ever, we bounced around like beach balls while rapidly moving through the ever so soft and easy riding roads of Iraq. Say it with me, y'all "weeeeeeeeeeee!"
"Let's go, Smith! We're loosing him!" my senior told me in between bounces and swerves. Our patient was in severe respiratory distress from his chest wounds. I did as I was trained to do and "sealed the box" using vented chest seals I pulled out of my Blackhawk Stomp II bag and my patient ended up receiving two NCD's, one on each side. The first decompression I did was in the 2nd intercostal space and the other I went 4th using my patients own hand for landmarking. Don't ask me why I switched it up. I was a cherry, thought maybe I should've done 4th the first time after he was still in distress, and I was panicking.
Our Iraqi soldier seemed to get allot of relief post NCD, however, he was getting paler and colder. With no exit wounds in sight, no active bleeding from the entrance wounds and vitals getting worse I was sure he had an internal hemorrhage. This guy needed whole blood products and a surgeon quick. With none of the sort available, his best option was to endure the safari ride in the back of our LMTV and hope we got him to a surgeon as quick as possible.
Our man arrived at our small resupply FOB alive and in serious need of whole blood products and a surgeon. We did every bit of our part, and the rest was in the hands of fate. It was only a few day's later one of my guys came up to me in a line and told me my man didn't make it. Honestly, I wasn't surprised.
I'm not sure what egregious offense that man committed to deserve what looked like getting fragged by his own team, but he was the very first casualty I ever treated, and the universe didn't throw me an easy one.
Story B: "Doc! Did you just oil check that guy!"
Afghanistan is so much fun; everyone should try it. (Sarcasm)
While moving through the Kunar province in Afghanistan in 2011, my convoy took a very intense contact. If anyone has ever had the pleasure, you know the roads that wind around the mountains of "the Stan" are pretty much just wide enough for single lane traffic of military vehicles.
While trying to push through the contact that was coming from across the river and the opposite mountain, we had a single jingle truck stop on one of the narrowest parts of the road, essentially halting the whole convoy in the middle of a firefight. Out-fucking-standing.
Myself and two others, Dwight and Eddie, came to the downed vehicle after I had already treated other partner casualties. This part of the story is so epic it's actually getting its very own blog. No joke, the truth is stranger than fiction and this was no exception.
Nearly twenty or thirty minutes after the fight was over and we had been moving miles down the mountain, I hear, "break, break, break. We need the medic up here." I immediately thought to myself, "What the fuck? Doe's the enemy have suppressors because I didn't hear any shots?" As it turns out, one of our local partners had been hit in the firefight we just left and didn't bother to tell anyone. Not only that, but he was also hit in his lower back, no exit wound.
As I'm on a knee beside my casualty I start doing my thing. Keep in mind, I'm not the green around the gills cherry that I was in the previous story. I'm fully experienced in some awful ways you never want to be and I was beginning to have nostalgia from my very first casualty in Iraq. This time, I took a very different approach concerning "sealing the box" and I did it with total chest pumping confidence.
Get ready for sacrilege; I disregarded the occlusive dressing completely. Every instinct in my body told me to pack that fucking wound and to do it tight. That goes against the most basic fundamentals we have in TCCC, which is to tie off the limbs, pack the junctions and seal the box. My patient had no respiratory distress, I knew the next COP was about thirty minutes away and he was s bleeder. I went with my gut.
I went through MARCH and packed his wound with good old-fashioned ace, kerlix and medical tape and kept an eye on vitals for possible respiratory distress development. (Spoiler alert, my patient lives.)
Like most things in life, your first reaction is usually the correct one. Don't start changing course after plotting your points, don't go back and change answers on a test and never second guess your instincts in moments of intensity. Argue with that, go ahead.
One of the last things I did before we packed him up in the MATV to move out was every medics favorite procedure, another credit card sweep to check again for internal bleeding. (That's also sarcasm) The last thing out of my teammate Eddie's mouth before we moved off the mountain was, "Oh my god, Doc, what the fuck! Did you just seriously oil check that guy?!!" Well, kind of.
Our team moved out and later pulled into COP Monti, about thirty minutes down the road. We brought our boy to the aid station, fully alert and alive. One of the first things out of the PA's mouth at the table was, "why isn't there an occlusive dressing on this?" I wasn't about to give him my personal thoughts on occlusive dressings in comparison to bleeding control when on the fence to do one or the other, so, I simply said; "No respiratory distress, sir." He glanced at me, looked me up and down and checked my rank on my plate carrier before turning to one of his medics and saying, "Go ahead and get an occlusive on that for me".
The end result, my "too lazy to tell anyone he was wounded" local partner soldier lived and the whole company was talking about the medic that oil checked his patient.
A tale of two houses:
(Disclaimer: I'm fully aware how different these two patients were in both injury and treatment. Remember... I was there. Untwist your panties, stay on track and take part in a productive conversation.)
It seems crazy that anyone, even at the highest levels, would argue that chest seals are not useful in trauma medicine. It's been engrained in our procedures and algorithms for so long that it almost makes you want to grab your torch, join the mob and burn the heretic at the stake who said it. But, when I look back from my own personal experience....hmmmmm...I'm not going to say the statement is correct, but I will say I have two stories that at least seem to fall in line with the argument. While my two patients are nowhere near comparable for a peer reviewed study, they were both situations where sealing the box would have been acceptable by the standards we teach and practice.
Our happy heretic isn't just anyone, y'all. Dr. Fisher is one of the most educated voices there is in tactical combat casualty care and has great deal of firsthand experience himself. In some cases, you might even say, he wrote the book. His acolades in medicine and combat far exceed mine.
He's also not coming to the argument empty handed, either. He has real peer reviewed data and his own personal stories of combat to support his argument. For everyone who is interested, I've attached a link bellow. Like I said, I'm actually honored to have someone at his level even glancing at my blogs.
I think it's going to be a long time before anyone stops the use of chest seals and sealing the box for a dirrect thoracostomy instead. It's such a grounded part of emergency medicine practice and education, both in the civilian world and the military. However, this has sparked my interest a great deal and I'll definitely be keeping up on how this one turns out in the future.
As for this guy, until the doctrine officially tells me otherwise, you can probably bet you'd see me "sealing the box" in the future, should the situation arise.
All honesty, still honored to be heckled by one of the best.
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