Alex Ooley (00:00)
Hello everyone and welcome to another episode of the Forge of Freedom podcast. I'm your host, Alex Ooley and this is episode 196 of the Forge of Freedom. Today I'm joined by someone you probably already know, Greg Ellifritz Greg, of course, was on the show previously when we discussed his book, Choose Adventure, Safe Travel in Dangerous Places. Greg is also a retired police officer with 25 years of service, 13 of those, I believe, as a full-time training officer.

He's also the founder of Active Response Training, a nationally respected firearms tactics and medical instructor, and as I mentioned, an author of his Choose Adventure book. My wife Whitney and I recently attended Greg's full day course, Tactical First Aid and System Collapse Medicine. It was actually the second time we'd attended the class. And this time it was at Blackwing Shooting Center in Delaware, Ohio. It's one of the most practical.

densely informative classes I've ever taken. I think that's likely true for my wife Whitney as well, who's also a physician assistant. So that's saying something about the merit and the content of the class. And today I want to bring part of that experience to you through the podcast. So Greg, good to have you on again.

Greg (01:14)
Thanks, thanks for having me.

Alex Ooley (01:16)
So ⁓ before we get into the tactical first aid and system collapse medicine material, if you would tell the listeners a little bit about your background. I know I gave a little bit of a short intro there, but if you would give the listeners a better sense for sort of the arc of your career and then also what led you to get into not only the firearms training, but also the tactical medicine aspect.

Greg (01:41)
Yeah, I became a police officer right after college. I was into martial arts quite a bit and shooting before I became a cop. I wrestled in high school and did judo all through college, a couple other martial arts. Ended up getting hired as a police officer about three months after I graduated college and was kind of surprised that there were very few.

of my fellow officers that did any additional training in shooting and martial arts. My first day, I met with the training officer of the department who issued us all the equipment and showed us how the guns worked right before we went to the academy. And I decided, this is the job that I want. I want to be the guy who trains everybody and lives on the shooting range all day.

I kind of structured my career to be in a position where I could take over that position when that officer retired. And so I started going to more combatives classes, more martial arts classes, and taking shooting schools on my own just to become a better shooter.

And about five years into my career, I got chosen to be the full-time training officer for the police department. The other officers hadn't done any additional work, and I was the obvious candidate despite my relative inexperience as a police officer. So that led to even more training. I worked for a police chief who was very pro-training, and he made me a deal.

told me he'd send me to any training I wanted to go to anywhere in the country as long as I brought the skills back to the officer. So I took full advantage of that. I'm asked, I don't know, I'm somewhere in the neighborhood of 4,500 hours of instructor training since I started about 90 different instructor certifications. For 13 years, I taught every single thing that the police department got with regards to in-service and pre-service training. So I got

all of the new officers, got all of the in-service officers, everything from the firearms and combative stuff to the legal updates to how to do traffic stops to how to do drunk driving enforcement to anything possible that the officers needed. They sent me to school to learn how to do it myself and teach it all in-house. And it's kind of interesting.

I got the, you know, very early on in my training career, I got the basic Red Cross first aid CPR instructor kind of stuff and was doing that. in the early 2000s, the war on terror heated up and the military, you know, developed this program called Tactical Combat Casualty Care and their combat lifesaver program.

it really kind of revolutionized how first aid was taught with some new equipment and some new protocols and that started filtering down ⁓ into the law enforcement world. So I started taking classes on how to teach that material to the guys. ended up getting a class taught by a guy who certified people in the tactical combat casualty care system for the military, a physician there.

I ended up doing the DEA's, Tactical Medicine Instructor School, Chicago Police Department's Tactical Medicine Instructor School. Took as many of this ⁓ military medical protocol classes that I could possibly take. Then about that same time, I started just for fun doing a lot of third world adventure travel. You mentioned my book. I've traveled to over 60 different countries now and most of them, you can't drink the water.

And I just started thinking, you know, one day I was, I remember I was in Peru and I was a three day canoe ride from the nearest town, which only didn't have any kind of air field or helicopter landing site. The closest town or the closest way to civilization was a train ride and the train only came a couple times a week. I sit in the jungle thinking, you know, I know all this basic first aid stuff and I know all the how to deal with gunshot wounds with all the military medical stuff, but.

I don't really know what to do if somebody really gets sick out here in the middle of the jungle and there's no hospital, there's no helicopter evac. So that kind of prompted me to start doing more wilderness medicine stuff. I did the backpacking and the wilderness medicine stuff, took a couple classes designed for third world medical missionaries, did some kind of crazy classes doing stuff that you could never imagine would even be taught now, this is 20 years ago. But... ⁓

amassed all of that and then kind of thought, I'm not a medical professional. I'm not a paramedic. I'm not an EMT. I'm not a doctor, but I acquired a high level of skill in this medical field. I know what to do for a lot of this stuff because of all the study that I've done. And I figured a lot of other people might be in a similar position. They don't have a medical background, but they're willing to put in the work and ⁓ learn some stuff.

put together kind of the best of all of the classes that I took and probably the most relevant material and started teaching it commercially and it's been a wild success. And right now, you know, I'm probably known most for my close quarter shooting and combatives classes, but about half of my class schedule is actually tactical medicine stuff. I get more students in the medical class than I do in my combatives and firearms classes right now.

Alex Ooley (07:00)
Yeah, that's great. As I said, I've taken the class twice, so that's, I think, a testament to how much ⁓ I think the class is worth. I'd take it more often if I could just to sort of hone my skills and sort of force myself to reconsider and think about these issues. But for people who might say, I'm not going to spend a three-day canoe trip from the nearest town, that's not your target audience, right? Even though

Greg (07:21)
you

Alex Ooley (07:26)
You know, those are circumstances that you sometimes find yourself in. the things that you teach in this class are really tailored to people who, are just everyday ordinary people going to and from work or to and from, you know, their, their, their job and home and, and they may be in a car accident or they may be, may come up on some sort of, ⁓ casualty event and those sorts of incidents where they're likely to need the skills that you teach in this class.

are far more likely to occur than maybe the necessity to use a firearm or deploy some sort of weapon in self-defense,

Greg (08:01)
Yeah, I think so. You know, I structure the class ⁓ for the most common kind of ⁓ traumatic injuries that someone might deal with, kind of the latest protocols for stopping the bleed and using tourniquets and pressure bandages and wound packing and all of that stuff. But then I kind of the second half of the class is mostly medical skills for if you are a little bit farther out from a hospital or a little bit

farther away from definitive medical care or maybe you're in a situation where definitive medical care doesn't exist. You could be the three day canoe ride up the river in Peru like me, but it could be something like a natural disaster like a Hurricane Katrina that kind of wipes out a hospital or a terrorist attack. I mentioned Mumbai terrorist attack where the bombers.

purposefully targeted the hospitals to get the doctors away from there. Could be something like that or it could be, you know, a full on zombie apocalypse kind of thing with, you know, no one's showing up for work for whatever reason and there is no hospital care. So it could be the hikers, the hunters, the outdoors people.

could be someone who is a little bit ⁓ living in a more remote area with a longer response time. I talk a lot about how to evaluate patients and treat them if you're a little bit farther out than the traditional, you know, urban or suburban areas where we're going to get an ambulance on scene in 10 or 15 minutes.

Alex Ooley (09:28)
So you cover a lot of ground in this class and you alluded to already the sort of the Red Cross style first aid protocol, the ABCs that we'll talk a little bit about here in just a moment, in contrast that with the tactical ⁓ combat care protocol and their MARCH acronym. But you've really developed this sort of as a, for laypeople who are not medical professionals.

Even though it's useful, like I said, my wife is a physician assistant. She's taken it twice. so she sees a lot of value in it as well. But because she doesn't get this sort of training in medical school or in physician assistant school. They are assuming, right, that the patient is in a controlled environment with certain tools. And if she came upon somebody out in a car accident or in some other scenario, she wouldn't be able to...

to apply those sorts of measures that she was trained to use in a controlled setting. So this is really, I think, applicable even for medical professionals.

Greg (10:24)
I once had a couple of emergency room physicians taking my class and they were absolutely amazed and they told me, they said, know, theoretically we knew all of what you were teaching, but we have a fully stocked hospital or a fully stocked ambulance to draw supplies from. And we have essentially unlimited number of people to help in various situations.

And we never thought about what to do if we didn't have all of this fancy gear or we didn't have the help of three or four other nurses, patient care assistants, other doctors working on someone. And I had to do it all by myself, you know, with

the kit that I'm carrying on my person instead of whatever I might have in the hospital supply room or the fully stocked ambulance. They told me that this is real valuable stuff even for medical professionals because it causes people to think outside of the box, outside of their normal daily existence.

and what can I do outside of this place where I have everything I need and it's a controlled environment. I have plenty of extra people to help me and if things get really bad, I can move them on to a higher level of care. So I think it's useful for that purpose.

Alex Ooley (11:44)
Yeah, and I think you give a lot of good food for thought too in the class about, know, not only do you not have the tools at your disposal that you might have in a controlled environment like a hospital or an emergency room setting or even just an ambulance, but the environment is going to be much different as well. You know, you may be still in a dangerous situation if it's a mass casualty event, maybe there's still a threat. And so you talk a lot about not only how to assess the

the casualty, but also how to sort of triage and prioritize which people to attend to first and what considerations you might take into account given the hostile environment.

Greg (12:23)
One of the fundamental things of every medical course I ever took was scene safety first. You don't want to make yourself another victim if you're trying to help out. assess the scene and don't provide aid if it's not safe to do so. But the military medical protocols are a little bit different because they might have to provide medical aid to someone.

in the middle of a firefight. That's not a safe scene. Yet they still develop the protocols to do that as safe as possible. But those protocols might be a little bit more aggressive than what we might have if we were in a controlled environment in a hospital setting, for example. If the bullets are flying and someone has traumatic bleeding,

I might want to very rapidly put a tourniquet on that person, whereas if that same bleeding in a hospital environment, we might just put a couple people holding hard direct pressure on it for 10 or 15 minutes to stop that bleeding. You know, the scenario is different because the environment's different and the sense of urgency is different, and that's something a lot of people don't think about when they think about medical care and kind of hostile or very...

very primitive environments.

Alex Ooley (13:41)
So ⁓ before we move on, if there's anybody who still isn't sure if they should listen to Greg on this particular topic, I will link in the show notes to Greg's training resume and his CV. He's got it available on his website. I think ⁓ you'll find it to be illuminating to how much training and experience Greg has not only in firearms, but in this particular subject matter. ⁓

Greg (14:01)
You

Your tax dollars at work. Your tax dollars at work.

Alex Ooley (14:09)
That's right. Yes,

exactly. Well, and for that matter, you know, well as anybody, Greg, how much of a luxury or a blessing it was to have somebody in charge of police department, the police chief, I assume, who was training oriented because so many people, I'm a criminal defense attorney. talk to a lot of officers on a regular basis. And one of the common problems is that they don't have a training budget or very little.

Greg (14:22)
Yes.

Alex Ooley (14:32)
training budget. It's just enough to do their annual qualification and that's about it. So yeah, it's great that you had that opportunity.

Greg (14:41)
Yeah, things change. You know, I when I got started in the training job ⁓ I had almost an unlimited but I wouldn't say it's unlimited but for the I had about 60 officers in my police department and we had a hundred and fifty thousand dollar training budget for those people for ammo and Out of town training any kind of that kind of stuff, you know, so everybody got a couple of decent classes a year and

We shot about 4,000 rounds a year when the time I was doing it. And then a new chief took over and completely eliminated my position and dropped that $150,000 a year budget down below $20,000 and went from training seven times a year with a couple of extra outside classes a year for each officer to just doing the state minimum qualifications. And it just.

went from training utopia to zero training within the course of a year. So it's tough, depending on the priorities, the bosses make the calls and some people have greater priorities in the training than others.

Alex Ooley (15:43)
Yeah. Well, I'm glad that the citizens in Upper Arlington, you know, paid for your training and experience. I'm sure they reap much of the benefit. I'm sure they were. Yeah. I'm sure they reaped a lot of the benefit as well, but certainly all your students and the people who read your website on a regular basis are reaping the benefit on an ongoing basis. So anyway, I'll link to that if you're curious about more about Greg's background. And with that said, Greg, let's get a little bit into.

Greg (15:49)
It worked out pretty well. It worked out pretty well.

Alex Ooley (16:13)
the topic we've alluded to already is this sort of contrast or difference in priorities between just your standard first aid and tactical first aid. Could you tell us a little bit about that?

Greg (16:24)
Well, know, a couple things, there's a couple differences between, you know, a standard Red Cross or American Heart Association first aid class and, and more of the tactical first aid. And the biggest difference is the mechanism of the injury. You know, the standard first aid classes you might get at your local firehouse or at your local hospital. I'm not discouraging anyone from taking those kinds of classes. That's how I started. And I think there's absolutely critical, but it is.

Primarily dealing with the most common type of injuries and illnesses that people see and Penetrating trauma from gunshot wounds knife wounds blast injuries that just isn't common even in busy urban environments the number of People who have fallen sick people people with chronic disease heart attacks car accidents

The number of those people vastly outnumbers the number of gunshot wound victims, even in the most busy area. So a lot of the first aid protocols are designed for those more common injuries that people are likely to see and don't include some of the more advanced protocols for dealing with ⁓ battlefield type injuries that we occasionally see. The other kind of issue is

the assumption that there's always going to be a higher level of care there. In all of the basic first aid courses that I ever went to, you know, the goal was stabilize the patient and then call EMS, get the ambulance there. But no one ever really covered what happens if there is no ambulance that can get to you. What happens if no one's going to come or what happens if the hospitals are shut down? You know, there's no additional level of thinking in the event that

things don't go perfectly and we can't refer our patient to a higher level of care. And then, you know, one of the other major differences is training and equipment. You know, I don't have my students for several years in medical school to get them up to speed. And like we mentioned before, they aren't likely to have a full hospital equipment room full of gear to treat their patients.

So a lot of my classes involve very simple aggressive protocols to stabilize the patient that can be learned and remembered easily without extensive amounts of training or a whole lot of additional practice and use improvised materials or materials that are ready at hand in the event that they don't have that ambulance coming for them.

Alex Ooley (19:02)
One of the slides that you showed in the class that I took a picture of is a slide about what kills people in combat. And this is going back to the points you've been making here. The standard first aid protocol is maybe it's good for your more common injuries, maybe the car accident type injury, depending on the circumstance, the slip and fall type injury.

But what if it's a situation, you use this example in the class, the Boston Marathon bombing or the shooting in the Aurora Colorado movie theater or most recently the stabbing of Arena Zaruzka or the knife attack on Arena Zaruzka on the Charlotte public transit or any other of these number of school shootings or church shootings, etc.

Greg (19:38)
Yes.

Alex Ooley (19:44)
What are the things that kill people in these more combat-like scenarios?

Greg (19:50)
Well, it's interesting. I bring up that slide because that was kind of the basis of ⁓ what informed the military tactical combat casualty care protocols. And that was a study done by an Air Force colonel. And he studied all of the combative in-service deaths from the Vietnam War up through the early part of the war on terror. And

What he found was that in combative environments, he classified the injuries as preventable battlefield deaths and non-preventable battlefield deaths.

there's some things we really can't do too much about you know somebody gets shot in the face with a high-powered rifle there's probably not a whole lot that we're going to do if they get their heart blown out of their chest by a load of buckshot we're probably not going to fix them those aren't preventable battlefield deaths but when they looked at the the people who died from combative injuries

and on autopsy they said hey we could have saved this guy if we would have done something a little bit different they classified those as preventable battlefield deaths and they found that the preventable battlefield deaths the leading source of the preventable battlefield deaths was bleeding to death from extremity wounds and the next biggest source of preventable battlefield deaths is a tension pneumothorax air getting into the chest cavity outside of the lungs

Comprovising the patient's breathing abilities and then the third which is a very small percentage only six percent of the combatives deaths was an airway related death, so it kind of flipped the Red Cross American Heart Association first aid Guidelines kind of on on their end, you know with the idea that you know our priority should we be airway breathing and then circulation when they looked at these combative battlefield deaths

circulation, bleeding to death was the greatest cause of death. So they had to change the algorithms a bit for penetrating battlefield trauma as opposed to everyday type injuries that most people would see. Not saying that either algorithm is better or worse than the other, it's dependent on the type or the mechanism of the injury that the patient has.

as to what is our treatment priority. if I, while I'm recording this podcast, if I fall over with a heart attack, ⁓ don't break out the tourniquets, please give me CPR. But if someone is bleeding to death from an extremity wound, we're not gonna worry about their airway really quickly. We gotta get that bleeding under control before they bleed to death. So those kind of issues come up when we start considering battlefield type injuries that aren't.

you know, the realm of normal first aid classes.

Alex Ooley (22:37)
So you mentioned the ABCs and how the Tactical Combat Casualty Care Protocol sort of flips the ABC order to some degree, and ABC is airway breathing and circulation. Before we get into the massive bleeding portion, would you go ahead and ⁓ tell us about the MARCH protocol, the M-A-R-C-H, just sort of outline that.

Greg (22:55)
Yeah, there's been several military or battlefield medical protocols that have been advocated in lieu of the ABC. The one that I like to teach is probably the simplest, it's called MARCH, M-A-R-C-H. Massive bleeding first, that's the ⁓ Then the A is airway. The R is respiration. The C is circulation, which is all other bleeding wounds.

and then the H is for head injury and hypothermia. And there's been some additional letters added on to that before and after the march, but the march protocols pretty much stand up and everybody's teaching something similar with maybe a little bit added on before or after that. I just tend to use the march when I find the students ⁓ gravitate to that pretty quickly.

So ⁓ that's a little different than the standard ABCs, which may be perfectly appropriate when grandma is choking on chicken bone at the Sunday dinner table, but less appropriate when somebody's leg gets blown off by an IED.

Alex Ooley (24:00)
Yeah. Yeah. And like you said, it's simple. It's easy to remember. It's something that people can apply in a high stress environment if they've taken the time to sort of internalize and think about these issues. You mentioned, I'm going back to this preventable deaths concept for a moment. There was this breakdown where the number one cause was penetrating head trauma, ⁓ which we can't do anything about with the MARCH protocol ⁓ in the field.

Greg (24:21)
Yes.

Not likely. Right.

Alex Ooley (24:27)
Then there's the next category, which was surgically uncorrectable torso trauma, which obviously if it's surgically uncorrectable, there's nothing we're to be able to do about it in the field. But then there's this following set, this sort of, it's the next category, this 32 % of preventable combat deaths that include potentially correctable torso trauma, bleeding from extremities, as you've mentioned, mutilated,

mutilating blast injuries, tension pneumothorax, and airway obstruction. And those are addressable or preventable with the MARCH protocol, right? So that's where we need to focus. And in the class, we cover the, you write the first four, so the MARC, but didn't really get into the, to the hypothermia, the head injury portion. Can you say a little bit about why we stick to the first four in the class?

Greg (24:59)
Yes, correct.

Yeah. ⁓

Sure, it's just a time constraint. I do two and three day classes where we do get into more depth with the H, the final thing. But hypothermia is relatively simple. We want to get our patients warm and dry. And I can cover that in two minutes. That's pretty easy. Head injury is a little bit more difficult. Head injury kind of includes everything from a mild TBI to that

penetrating trauma to the brain. And it's very difficult to teach people all of the nuances of dealing with head injuries in a short-term nine-hour class format. So ⁓ in the class that you took, I focus on being able to recognize head injuries and refer them to a higher level of care. What bumps on the head can be handled?

you know, with an ice pack and a little bit monitoring and when do they need to go to the hospital? And so I do the limited time constraints. I just focus on those type of stuff for treating the head injuries is is diagnosing. Hey, this is something that needs more skill than I have. And this person needs to go to the hospital as soon as possible. And that's where I kind of leave it with that class, because, you know,

It's another four to six hours to cover all of that material that I would normally cover if I had a two or three day class to do it.

Alex Ooley (26:48)
That makes sense. One statistic that you gave before we get into the massive bleeding is that 90 % of Vietnam casualties would still be alive today if we utilized the Tactical Combat Casualty Care Protocol. Where does that statistic come from? I mean, that's just almost unbelievable. So could you say a little bit about that?

Greg (27:03)
Yeah.

Yeah, one of the military medical doctors that taught one of my ⁓ classes, he actually taught the DEA tactical medicine class. He's a military medic, reserve medic, and worked with one of the doctors that did this research. And he's the one who gave me the statistic on there that 90 % of the casualties in the Vietnam War, if we had our

current military level of medical care, 90 % of those people would still be surviving today. And what the focus of that was is very rapid evacuation to definitive care, which we didn't have so well in the Vietnam War, and aggressive treatment of serious bleeding. know, tourniquets were

still kind of demonized back in that time. know, tourniquets is the last resort and a lot of people bled to death because people were afraid to put tourniquets on. So the combination of the two better transportation to definitive care and more aggressive treatment of very serious bleeding. The estimates are that 90 % of the casualties in Vietnam would still be alive today.

Alex Ooley (28:22)
Yeah, that's amazing really. And speaking of tourniquets, so that's a good transition to our first portion of the March Protocol, massive bleeding and tourniquets. We talk about direct pressure, pressure dressings and tourniquets. Could you tell us a little bit about what that ⁓ in the March Protocol is all about?

Greg (28:44)
Yeah, you know, when I first learned first aid, you know, as a as a kid in Boy Scouts, we were taught kind of to control bleeding first with direct pressure. And if that didn't work, we combine direct pressure with elevation. We elevated it if it was an extremity. And then if that didn't work, then we try a pressure point. We would try to occlude a major blood vessel upstream of the injury to reduce the bleeding.

And what the military found when they developed the tactical combat casualty care protocols were that people were applying that algorithm, the pressure, then elevation, then pressure points. And by the time they got through all of those methods of care, the person had bled to death because, you know, if we have a very serious arterial bleed, depending on, you know, what vessel was cut and

and the heart rate of the patient, someone could bleed to death in two to four minutes. So by the time they tried and evaluated all of those protocols, they were finding that people were bleeding to death. So they needed a more simplified algorithm. in the military protocols currently, the protocols are direct pressure or pressure bandage is still our first bet.

And that you know, it's estimated that if we have good direct pressure or really tight pressure bandage that will solve about 95 % of extremity bleeds and then the the new part I say new This is 20 year old technology now, but the new aspect of this is recognizing that hey my pressure my direct pressure with my hands or the pressure bandage isn't working

I need to really quickly transition to something that will work and on an extremity that's going to be an aturnicate. So ⁓ very quickly going to the aturnicate if the pressure isn't working. So one of the major advances in the military medicine that has just been filtered down into the civilian world within the last 10 to 15 years, I was teaching this stuff to my officers.

as early as 2007, equipping my officers with tourniquets and pressure bandages in 2007, our ambulance, our medics didn't get tourniquets until 2018. So a lot of this took a long while to filter down into common medical stuff. But now with the Stop the Bleed classes that are very common, we're seeing more and more emphasis on the tourniquet.

Alex Ooley (31:20)
Yeah. And so direct pressure can be applied with the hands, but if you're in a situation where you need to use your hands, right, or your hands aren't available to address an ongoing threat or to assist other people, that's where the pressure bandage or the pressure dressing really becomes useful. And you talk about two, primarily the Israeli bandage and the H bandage, which is used by the Marine Corps, primarily from my recollection, because they were concerned about

the pressure bar breaking on the Israeli bandage. But my recollection was that you've never seen one broken on first time use, but only with repeated use on the Israeli bandage. Is that right? Yeah.

Greg (31:57)
That's true. I mean,

if you look at the two, the H fastener of the H bandage versus the pressure bar of the Israeli bandage, the H fastener is definitely a little sturdier. I think it's theoretically possible to break the Israeli bandage with a very aggressive.

But I haven't seen that with any new ones now I think a lot of that comes from you know We reuse bandages in practice and over time that plastic starts to weaken and they break but Although it's probably possible. I have not seen one break right off the bat new from the package

Alex Ooley (32:36)
And speaking of practice, you allow your students the time to practice during class, applying it to somebody else, and then also applying it to themselves, which could be potentially a very important skill to know how to perform. And then you talked about this direct pressure works on about 95 % of bleeding wounds. But how do we figure out when we move on to the tourniquet? And you need to do it relatively quickly in about...

two minutes, right? So if you're applying direct pressure with your hands or with a pressure bandage and it's still not working, you move on to the tourniquet from there. With a pressure bandage, how do you do that? Do you see it bleeding through or do you take it off and see if it's continuing to bleed? How do you make that assessment?

Greg (33:02)
Yeah.

No, you wouldn't take it off. It would be either bleeding through or escaping around the edges of the bandage and coming out that way. I wouldn't give it a whole lot of time. The issue, I said it could be two to four minutes, but we don't know how long this person's been bleeding before we got to the scene. So if I saw any evidence of it, gushing blood that is coming through the bandage, I would very quickly move on to the tourniquet.

The other two indications of the tourniquet even before the pressure bandage, if you see spurting arterial bleed, if it's spraying blood out, we're going to go for the tourniquet as the very first intervention. And we're also going to apply a tourniquet on any type of traumatic amputations. So we're looking for spurting bleeding, any amputations, they immediately get a tourniquet. Anything else, we're going to try direct pressure first.

But we're going to move on to tourniquet really quickly if we have any indications at all that that pressure is failing and they're still bleeding.

Alex Ooley (34:16)
And we talked a little bit about improvising the pressure bandage with a, you know, whether it's a, like a bandana type material or some other type of material that can be important, especially if you have multiple casualties and you only have one pressure bandage or two pressure bandages, being able to improvise is important. And then wound packing, you talk a little, a lot about gauze and packing wounds on extremities, you know, and

I can't remember the three products. was C-Locks and QuickLot. HemCon was the third one. couldn't. Okay. And there were various pluses and pros and cons to each of those that you got into and a fair amount of detail in the class. But one thing that you said adamantly not to use was a tampon. Can you talk a little bit about why that's wholly inadequate for this purpose?

Greg (34:45)
CLOCKS, QUICK CLOT, and HEMCON are the three... yep. ⁓

Mm-hmm.

us.

Yeah, so we pack wounds that are, if they're on extremities and they're big wide gaping wounds and pressure at the surface of the skin doesn't get to the vessels bleeding down in the muscle tissue, we might pack that wound, but more commonly we pack the kind of wounds where in areas where we can't put a tourniquet on them. So the junctional areas where the

arms or legs meet the body, where the neck meets the body, those areas that we can't put a tourniquet on, we're going to pack those wounds full of gauze, ideally full of a gauze that has a hemostatic agent, those gauzes that we mentioned that help chemically control the bleeding. But if we don't have that, we're just going to pack them deeply and densely with regular gauze and allow direct pressure to stop that bleeding. But in order for that pressure to work,

we need enough material to actually put pressure on the bleeding vessels. And a lot of people think I'm just going to plug the hole with a tampon. But bullet holes are a little bit more complex than people think. They often go fairly deep, and they're often bigger inside than the hole in the surface of the skin might indicate. And just merely

plugging the hole in the skin with a tampon doesn't address the deep bleeding that is in the muscle tissue far deeper than that. And there's just simply not enough cloth, not enough material to provide pressure onto that bleeding vessel to get that blood vessel to stop bleeding when you're using a tampon. You need lots and lots of gauze. I mentioned in class, I did a medical class once where we contracted with a local farmer and he

killed a couple of his pigs and we then shot the dead pig carcasses with various self-defense handgun rounds and we had the students packing those actual bullet wounds on real flesh, dead pig flesh, but it is actually real flesh and you know we were using almost two full rolls of gauze to pack a nine millimeter wound in the pigs hindquarters.

And when you look at a tampon, it might be a three inch by three inch piece of soft cotton when you unfold it and unroll that cylindrical tampon and open it up. It's not nearly enough material to provide that dense pressure. need to stop that bleeding deep down in the wound.

Alex Ooley (37:34)
Yeah. And you give, even in the classes where you don't have a local farmer, you know, at your disposal with some pigs to use, you have this gelatin that's an approximation of the sort of the human, the density of the human body. And you let students pack the C-locks or the quick lot type gauze into these gelatin blocks. And it really gives people a conceptual reference for how much gauze it takes to pack even just a small

few inches of a wound. It's really pretty amazing. ⁓ But like you said, the helox or the C locks, the quick clot, the hem con, have, coagulants basically are chemicals in them that help, stop the bleeding. So not only are you putting pressure, you're getting the chemical benefit of those bandages as well. Yeah. So,

Greg (38:01)
Yes. Yeah. Yeah.

You have to speed up the regulation.

Yep. Correct.

Alex Ooley (38:26)
We talked at a high level at least about direct pressure and pressure bandages. Let's get into tourniquets. And you mentioned earlier that, you know, years ago tourniquets were sort of demonized and, you know, people didn't use them, but that that's changed. Could you talk a little bit about some of the misconceptions about tourniquets and ⁓ just sort of some guidelines for how they should be used?

Greg (38:48)
Yeah, it's been changing quite a bit. remember when I was in Boy Scouts in 1970s, we learned how to make a tourniquet out of our Boy Scout Neckerchief. And we're taught that that was kind of the last ditch effort to stop bleeding, but it was perfectly acceptable. And then moving into the 80s and early 90s, tourniquets kind of got demonized. People started using them a little too much.

started using them inappropriately in situations that didn't need tourniquets and were using tourniquets that weren't there were very few commercially designed tourniquets at that point in time so people were using ropes and belts and bungee cords and all kinds of crazy stuff as tourniquets that were too narrow that wouldn't effectively stop the bleeding and would cause a lot of nerve damage because they bit too deeply and that kind of stuff so

You know, the general guidelines were only tourniquets should be used, you know, if, you know, that was the only thing that could stop the bleeding last ditch. We thought that as soon as we put that tourniquet on, everything downstream of the tourniquet was going to die and they'd need to be amputated. And a lot of hype was put on this, the dangers of the tourniquets. And once the military started using them very aggressively in the war on terror, they found that there weren't

as many dangers of a properly applied commercial, a tourniquet, as there were with somebody using a belt or a zip tie and a stick, you know, back in 1984. So the tourniquet use became a little bit more prevalent in the military, a lot more prevalent in the military, and became kind of the go-to for bleeding control.

Once the military's research found that it's very rare to have any kind of downstream injuries of the tourniquet, properly applied tourniquet, within about a two hour time period, the military started using tourniquets on a lot of bleeding injuries, probably a little bit more than what's needed. And we're kind of seeing that now. You're seeing lots of ⁓ body camera and cruiser camera videos of police officers using tourniquets on almost every bleeding injury that there is with

probably not unnecessarily, but once we found out that it didn't quite hurt people as badly as we thought and we've got a two hour buffer between a properly applied tourniquet and any serious damage going on, tourniquet started getting more and more commonly used. And I think it's...

Probably it's within the cycle now where it might start getting overused again. We're getting some new research out of ⁓ Ukraine the war going on there with lots of improvised tourniquets and lots of tourniquets applied in various situations and We're seeing a little bit more damage coming back because improperly applied tourniquets or ⁓ Tourniquets applied that are ⁓ not commercial tourniquets or tourniquets that are put on for too long

And we're seeing some limb injuries downstream of those tourniquets now. So it's just kind of the normal cycle. It was fine and then it was not fine and then it's fine again. And I think people are going to start using them too much and they'll rein them back. So it's just kind of the normal cycle of how things work.

Alex Ooley (42:00)
Yeah, they'll overreact in the opposite direction, unfortunately. So you talk about two types of tourniquets in particular. You have a number that you bring to the class just so students can see, but there are two in particular that are emphasized, the cat and the soft T. And a lot like the pressure bandage, you let students apply them both to another student and to themselves. And there are significant differences in how they are applied.

Greg (42:03)
Yep. Yep.

Alex Ooley (42:26)
Could you tell us a little bit about these two types of tourniquets and what are the pros and cons of each and what should people look for when they're buying one?

Greg (42:36)
⁓ For a long while in the early 2000s those two tourniquets the cat tourniquet from North American rescue and the softy from tactical medical solutions were the only two tourniquets that were Recommended by the Committee on tactical combat casualty care for the military This is a committee of doctors and medics and nurses that sort out best practices and they also do studies to

cast various pieces of gear and either recommend them or not recommend them for wider use within the various military services. And for many, years, close to 20 years, those were the only two tourniquets that were recommended. 2019, they approved a few more tourniquets that got the committee's recommendation. And I let people play with those as well. But in

20 plus years of playing with this stuff, you know, at least on a monthly basis, I found that my students tended to do the best with the cat and the soft tee. They could apply them the quickest and easiest and there were fewer complications with the cat and the soft tee as opposed to some of the other tourniquets out there. There are now lots of tourniquets available on the market and most of them will stop bleeding.

And you know, I get students pretty regularly say, I've got this tourniquet or that tourniquet that I bought and I put it on and I don't have a distal pulse after putting it on. It's clearly stopping the bleeding. And they're absolutely correct. That's kind of the basic function of the tourniquet is to stop the bleeding. But you know, what the military testing is doing is looking at other things in addition to just merely stopping the bleeding. We're looking at how quickly can that tourniquet be applied? Are there any kind of

problems with the tourniquet getting wet or muddy or icy or slippery? What happens if it gets bloody? Can it be applied quickly? Does it stay on if the casualty has to move in a combative environment? Does it cause more injury? Does it cause more pain? All of those factors tend to be the factors that make this

committee not recommend other tourniquets, not the fact that they don't stop bleeding. There's several decent tourniquets that people carry around with them regularly that do find stopping the bleeding, but they take three or four times longer to put on than the CAT or the Softee. So the military, you know, and doing all their product testing says, hey, you know, if this one works, but it takes four times the amount of time to get secured,

then why aren't we going with the other one? So through all of my experience, all the training that I've gone to, all the times that I've seen students put these things on, I found that the Cat and the Soft T are probably the most reliable and easiest to use. I would recommend as far as buying them, there are a lot of counterfeit tourniquets on Amazon and eBay and some of the Tmoo type foreign sites.

that you might buy stuff for. With tourniquets in particular, I would not buy them from any source other than the manufacturer or the manufacturer's designated retailers. So you're looking for North American rescues designated supplier or tactical med solutions for the softee. I wouldn't buy those things off of Amazon, eBay, or some discount internet site.

Alex Ooley (46:01)
Yeah. So before we move on to the airway and respiration, as you mentioned, this is a nine-hour class. We're not going to get into all the details of each of the elements of the MARCH protocol. But before we move on, could you say a little bit about sort of this controversy? I don't know if it's a controversy, but this disagreement at least between where to place the tourniquet, whether it's high and tight on the limb or more directly above the wound on the limb.

⁓ Could you say a little bit about that?

Greg (46:33)
Yeah, doctors and medics have been arguing about this for 30 some years about placement of the tourniquets. Back originally when we first taught tourniquets, the thinking was we want to minimize the affected area downstream of the tourniquet because we thought that the area would be damaged if we kept that tourniquet on. So they put the tourniquet

couple inches, two to three inches above the wound was the standard placement. That's how I was, I originally taught how to do it in Boy Scouts, two to three inches above the wound. That made it into the initial tourniquet placements of the original tactical combat casualty care. The military started

having some situations where that didn't quite work so well. You got to look at what's going on in a military tactical environment. Often these operations were happening at night. Often, you know, the military folks were wearing full ⁓ clothing and it was relatively difficult at night. You know, say someone gets shot in the leg, you know, how do you determine exactly where that injury occurs if

it's nighttime and they're wearing pants and you don't have time to cut away the pant leg, how do you determine where this injury is so that you can get that two to three inch buffer right above it? So the military quickly changed to a guideline as in combative environments, placing the tourniquet as high up on the limb as possible is the right answer.

We found two things. find that the tourniquet work a little bit better when they're constricting around one bone as opposed to two. So higher up in the limb, in our legs and our arms, we have a single bone rather than two bones. So it works a little faster around the single bones. And the other issue is that if we shut off all of the blood flow to the entire limb, we don't have to visualize exactly where that injury is. Just kind of covers all bases. And once we realize that it

really wasn't that dangerous to put a tourniquet on, that became the guideline. But they're continually fighting about this. the military guidelines are in combative environments, we want to place this tourniquet as high up as possible. But in a stable field hospital type environment where the bullets aren't flying, placing it a couple inches above the wound is not a wrong answer either.

You look at some of the wilderness medicine guidelines, they still teach, you know, two to three inches above the wound. So it kind of depends on your environment. I don't know that either is necessarily wrong. If I have a very clearly identified wound and I'm not under the stress of somebody shooting at me, maybe going down a little bit lower isn't a terrible answer. ⁓

But if I have to do this in a hurry, I've got a whole bunch of people that are injured that I've got to treat, the bullets are flying, I can't visualize the injury, defaulting to moving high up on the limb as possible I think is the right answer. I think for most people in most environments, I think going higher up on the limb as possible is probably the right answer for most people.

Alex Ooley (49:49)
Yeah. And like you said, especially now knowing that it does very little damage, if any downstream of the tourniquet, especially over a couple hours sort of timeframe. So most people are not that far away from emergency medical care. Yeah. All right. So let's move on to that. We covered the massive bleeding, at least at a high level. And we talked about actually the H a little bit at the beginning, but I want to get to the ARC portion.

Greg (49:59)
Yes.

Correct.

Alex Ooley (50:16)
So let's talk a little bit about airway and respiration, which of course would be sort of the first part of the ABC protocol, but it's now the second part of the MARCH protocol. What should folks know about airway and respiration?

Greg (50:34)
Well, you know, the airway, think oftentimes people confuse the two, conflate the two, airway issues versus respiration. When we're talking airway, we're talking about a physical blockage of the airway due to some foreign material or due to a position that the person is in that physically occludes the air from going into the lungs through the mouth. When we're talking respiration, that is the act of breathing itself.

You know, those two are separate. You know, you could have a blocked airway and still have the musculature to take a breath, or you could have a completely clear airway and not be able to breathe because of, a chest wound where you can't draw air into your lungs. So we start off with just the basic airway to ensure that they have a patent tube going from either their mouth or their nose into their lungs so that we can perform the task of breathing.

⁓ without any difficulties. So in the class we cover how to assess some of the airway difficulties and then what to do. We primarily deal with that with positioning of the patient. We do a chin lift to open up their airway a little bit and then we cover some ⁓ other airway adjuvants such as a nasal pharyngeal airway, putting a tube in their nose.

to run down into the back of their throat to kind of bypass that area where the tongue blocks the back of the airway in some patient's positions. And more importantly, when not to use those kind of nasal pharyngeal airways. And then we talk about what to do, how to position the patient so that their airway stays open so that they can breathe on their own. And then we get to the respiration issues. And the respiration issues in a combative context is primarily

dealing with chest wounds that allow air to build up inside the chest outside of the lungs. So air is getting into the chest cavity through a hole in either the body cavity or a hole in the damaged lung tissue.

And it's building up, but it's not getting processed by the lungs. It's not making it into the circulation and the blood supply. And that air buildup eventually causes the lungs to stop functioning, to collapse for lack of a better term and move away from the injury. And people stop breathing and they die in that process, normally called a tension pneumothorax. So we cover how to identify one of those and what to do about it if we have one.

Alex Ooley (53:08)
Yeah. And one of the things you mentioned at the end of each segment after the massive bleeding, that portion, the addresses 60 % of preventable deaths and then the and the A together is 66 % and then the MAR is another, I don't remember what the statistic is here offhand. ⁓ Okay.

Greg (53:26)
The respiration is 31. So if you

look at 60 % is the bleeding from extremities, 6 % is the airway, 31 % of the preventable battlefield deaths is from the respiration, the tension pneumothorax. So we put the airway first because it's a relatively easy fix. And we can't really isolate if they're having difficulty breathing for the respiration part unless we ensure that they've got an open tube that that air can move through.

We go with the airway initially just to make sure that the airway is open primarily through positioning the patient and then we focus on the respiration. Once we've got the airway open, let's make sure that we can keep breathing.

Alex Ooley (54:12)
Yeah, and you emphasize this in the class, but in a trauma-related scenario, CPR is not going to be effective where there's this tension pneumothorax going on or some other issue. We talk a lot about in the class the issue with opiate overdose. ⁓ Those issues are unique and difficult to address with something like CPR.

Greg (54:30)
Yeah.

Yeah, you know, a lot of people have misguided ideas of what CPR does. You know, in very few cases, does CPR actually normalize the rhythm of the heart? You're doing CPR essentially to provide a little bit of oxygenated blood supply to the body to buy yourself time to either get the electric shock, the AED, the defibrillator or the cardiac.

You aren't fixing them with CPR. And so in a battlefield kind of context, the military guidelines for the tactical combat casualty care are not to do CPR when the bullets are flying, because it has such a low success rate in and of itself, absent the electric shocks and the cardiac drugs, that it's just not worth risking another soldier to do this with a low likelihood of success.

So they focus on dealing with those chest injuries rather than doing CPR, which would be the respiration that you would get in a Red Cross first aid class.

Alex Ooley (55:37)
Yeah. And we talked about packing wounds earlier, but you talk, you mentioned obviously that's just going to be on the extremities and typically the junctional areas. We're not going to pack the chest or the abdomen, right? But there is ⁓ something that we commonly refer to as stickers or chest seals. Can you talk a little bit about what those do?

Greg (55:58)
Yeah, what the chest seals do is they prevent air from getting into the chest cavity from the outside of the body through a hole like a gunshot wound or a stab wound, that type of a thing. There can still be a way air can get in through the injured lung tissue, but if we minimize the amount of air getting in from the outside.

we can slow or reduce the chance of having that tension pneumothorax with those lungs collapsing and not working because of the air buildup in the chest. So we treat chest injuries initially by putting a type of, it's a big plastic sticker. It's almost kind of like one of those glue mouse traps that you might have in your home. It's a really sticky piece of plastic that covers the wound.

to prevent air from getting into the chest cavity from the outside.

Alex Ooley (56:50)
Yeah. And then if that doesn't work, that means the air is still getting in somewhere, which usually means it's through a punctured lung, right? And the only way to get that out is through like a needle decompression, which is a little bit more complicated obviously than simply slapping on a sticker. But you talk a little bit about that in the class and I think you said this would be like a paramedic level type skill.

Greg (56:57)
Yeah, correct.

Yeah, would...

Yeah, they used to teach it in the combat, tactical combat casualty care, the combat lifesaver. I, to best of my knowledge, it's not currently in the curriculum. They used to teach it to everybody. The needle decompression, putting a big needle into the chest to vent that air out. People screwed it up pretty significantly.

The danger is we hit some structure in the chest that we don't want to hit like the heart or a major blood vessel or nerve and cause more problems than we're fixing so we talk about how to recognize attention pneumothorax and how to position the patient to minimize the effects of the tension pneumothorax and then kind of as a last resort how to burp or vent those chest seals to manually get air out of the chest cavity without having to

give your patient a chest tube or stick a big needle into their chest, is, you know, probably set you up for something that the Good Samaritan Act isn't going to cover on you. So ⁓ we work the manual verbiage.

Alex Ooley (58:10)
Yeah. Yeah. Yeah. You, you weren't, you,

you weren't really promoting the needle decompression in the class, but I think I just wanted the, wanted people, the students to understand what it was, how it worked, sort of conceptually. but then there's, like you said, there's this alternate treatment that, most people could do, which would be the wound burping where, where you uncover the wound to allow it to vent during the patient's exhale, right? During the respiratory pause.

Greg (58:18)
No.

Sure.

Yes, correct.

Alex Ooley (58:38)
To try to

Greg (58:39)
Yes.

Alex Ooley (58:40)
relieve a little bit of that pressure a little bit at a time. Right? Okay. So, finally, I alluded to this earlier and these numbers are just kind of staggering. We talked about opiate overdoses. 30,000 to 40,000 car crash deaths every year. 30,000 gun deaths and over 100,000 from drug overdose. So, more than...

Greg (58:43)
Yes. You got it.

Alex Ooley (59:07)
car crashes and gun deaths combined significantly more. And really the best and most effective treatment for that, if somebody you know, a loved one is suffering from it or somebody you come across on the street is Narcan, right? Is that... Yeah. And one interesting thing I didn't know before I took your class the first time is that there's no effectiveness to giving the person more than

two doses, one up each nostril. Could you say a little bit about that?

Greg (59:33)
Yeah,

the nasal passages can only absorb so much of that fluid. They get saturated and it can absorb additional amounts of drug. So they might need more Narcan, but that's going to have to come from either an injection or an IV rather than the nasal applicator that most of you can get over the counter at the pharmacy now. The general guidelines for Narcan use is we're going to squirt one

dose up a nostril and we're going to monitor their breathing for a couple minutes and if the breathing doesn't improve we're going to give them a second dose up the up the other nostril and that's about all that will work you know in some patients there might be a marginal benefit of a third but probably not the general guideline is two is about all of the body can absorb so if two doesn't work

they need a higher level of care than what you can provide. At that point in time, you might try rescue breathing. If you're comfortable doing that, you can breathe for them until that opiate drug wears off, which may be a while, or until medical help gets there with IV access or injectable Narcan.

giving them repeated doses multiple beyond two doses of Narcan intranasally isn't going to solve your problem.

Alex Ooley (1:00:55)
Yeah. And some, and you addressed this to some degree in the class too. Why, why would I care if, especially if it's not a loved one, a lot of people don't relate to this problem. Um, why do I care if I come across somebody who's overdosing on the street? And I thought this, this overlaps a little bit with, uh, some of the things that Masada, you, for instance, teaches in, in, um, mag 40 about sort of the, psychological aspect of taking another person's life. So even though.

when you come across somebody who's overdosing, you're not the one taking their life. There's still some psychological aftermath there. And you mentioned that even though that person may have been a dirt bag, you know, that you're better off spiritually or mentally or whatever for having at least attempted to save their life.

Greg (1:01:43)
Yeah, I worked in Ohio and you know from 2013, 2014 to about 2018, Ohio was right at the top of the list of overdose deaths in the country. And we were going on lots and lots of overdoses. And in my early days, we didn't have the intranasal Narcan at all. And there was very limited

things that we could do as first responders to fix these people who had stopped breathing from an opioid overdose. And later on in my career, we ended up getting the Narcan and we ended up Narcan-ing quite a few people. And I could just tell you that having been on numerous calls where I was relatively impotent and could do nothing and just basically watch these people die,

versus being able to revive them by squirting some stuff up their nose. I just say that it felt a lot better being able to save these people's lives than actually sit there and watch them take their last breaths, even knowing that most of these drug addicts are not real good human beings and they may not lead a very productive life. I think it still takes a toll on first responders just watching people die.

unable to do anything. think there's a psychological cost and once we got the Narcan that got a whole lot better at least in my mind for the patients that I work.

Alex Ooley (1:03:08)
Yeah, and it's relatively easy to obtain, right? I think you mentioned in some states that you can get it for free from your local health department. And even where it's not free, it's still relatively easy to get.

Greg (1:03:19)
Yeah, last year, maybe two years ago, ⁓ FDA made it over the counter. There's no downsides to incorrectly applying it. That's the thing. If you squirt some up somebody's nose who is not suffering an opioid overdose, it's not going to make anything worse. It's not going to have any negative side effects. The only thing that that drug does is it preferentially knocks the opiate molecule off of that receptor in the brain.

stops it from working and that's all it does. So if you misdiagnose your patient and spray that stuff up his nose, it's not going to hurt him at all. it's over the counter now. You can buy it at your local pharmacies. Lots of health departments will give it to you for free. There's lots of harm reduction organizations that will give away free Narcan. I drive a lot.

teach in various classes and quite regularly at the vending machines at roadside rests in states all over the country, they have vending machines that distribute free Narcan right next to your candy bars and soda pop that you'd get at your rest stop areas. They're available pretty easily all over the place.

Alex Ooley (1:04:27)
So we've gone a little bit over an hour at this point. I want to make sure we cover the C of the MARCH protocol and then the system collapse medicine portion, which is a bit of a differentiator between your class and other tactical combat care, casually protocol type classes.

So in terms of the C portion of the MARCH protocol, circulation, wound care, we talk about infection some. Could you tell people what this portion of the protocol is all about?

Greg (1:04:57)
Yeah, what we're looking for there is any additional bleeding wounds. lots of more minor wounds might get missed on your initial assessment and how to care for those. So in the class, we talk about doing a more thorough assessment to find all of the bleeding injuries that your partner might or your patient might have. And then we talk about use that kind of as a transition to go for

more of a long-term wound care type of treatment protocol. a lot of your tactical combat casualty care stuff is just, you know, put a bandage on it, get them to the hospital. But, you know, in the focus of the class, my class being, well, what if there is no hospital? We get into some more in-depth of how to clean and disinfect wounds. What's good practice for dealing with other types of

bleeding injuries, when to close wounds, when not to close wounds, and some of the methods for wound closure. And that's what we cover with it in my class.

Alex Ooley (1:06:00)
Yeah. Yeah. And in fact, this is like I said, this is the second time I took the class. In the first class, I didn't get to practice doing sutures of any kind. But in this one, you had the students take a crack at it if they wanted to do stitches, ⁓ stitches and staples. Yeah.

Greg (1:06:15)
Stitches and staples. Yeah

It's it's tough to travel with all of the gear that I need to teach suturing and stapling and all of that more advanced wound closure stuff You know lots of instruments we need we need practice materials something that they can practice sewing on all of that kind of stuff but I teach at Blackwing where you took the class enough that I

you know, keep a stash of supplies there permanently. So I don't actually do the live suturing and stapling in a lot of my classes, my travel classes, at least some of the local ones that I do that I can travel with that stuff. But at Blackwing, ⁓ I've got a full supply of all of that gear and I leave it there and allow the students to play with it a little bit. It's kind of interesting. I don't really think it's super useful to teach suturing.

but it really draws a lot of students. It's kind of like, you know, giving them a little bit of ⁓ candy to make them eat their vegetables. We initially tried doing that class without offering the live suturing and stapling aspects of it. And we had about 30 to 40%, depending on the class, fewer students sign up for it.

a lot of the students think it's really cool to learn how to sew. And it is. The first time I learned it in one of my classes, I thought, is really cool. I've known how to do it for 20 years. I've done it exactly twice. And I probably didn't need to do it on either of those people. But I did it because I could. And it was fun. And they wanted me to. So I don't know that it is all that useful. And I cut it out of a lot of the classes because

Alex Ooley (1:07:26)
interesting.

Greg (1:07:49)
It isn't that useful, it is a fun skill to learn. It's not a bad thing to learn, and you may use it in some long-term capacity. I present it a little bit. You're not going to get enough practice to become proficient in it my class, but I provide you with enough resources that you can do some further practice and study on your own and get pretty good at it if you need to.

Alex Ooley (1:08:09)
Yeah, well, I agree. think it's not particularly useful or practical to know how to do it. ⁓ At most, your wound is just going to heal up a little more nicely, right? If you don't have access to some place to get stitches professionally done. But it is really fun to learn and yeah, it was enjoyable. But more importantly, we talk about what to look for and what to do before you close up the wound, including how to clean it.

Greg (1:08:18)
Yes.

It is.

Alex Ooley (1:08:34)
How do you flush out the bacteria, especially if you're not in a place where you've got maybe access to clean water or how do you purify the water, those sorts of things. And then we talk about antibiotic ointments and considerations there. The water portion was interesting, especially since you travel so much. Have you ever come across a situation where it was difficult to have access to clean water and there was a wound situation?

Greg (1:08:57)
I have several times in South America, one time in Africa, water is usually available. You know, I don't do a whole lot of desert travel. I do a lot of more jungle kind of stuff. So water is usually available, but it's not clean. know, one of the things that I do is I generally ⁓ carry multiple methods of water purification. But one things that I do is I will put some water purification tablets actually in my first aid class, in my first aid kit.

earmarked for purifying water just to be used for wound flushing. So we need a lot of water to physically flush any kind of bacteria out of the wound. And so we're going to need clean water to do that. And the research shows that if it's clean enough to drink, it's clean enough to disinfect a wound. doesn't need to be sterile saline solution or anything like that. Anything that is potable tap water or, or

disinfected river water. Anything that's clean enough to drink is clean enough to clean your wounds with. But we generally need a large amount of that. So I actually throw some water purification tablets into my first aid kit just so I have enough just in the event that I need to purify a lot of water to deal with wound disinfection and cleaning.

Alex Ooley (1:10:10)
Yeah, I was actually surprised at the amount of water that it takes. A quart of water under pressure for every inch of length of the cut to flush out the bacteria. So that's a lot.

Greg (1:10:17)
That's Yeah, that's the Wilderness Medicine

Society guidelines. Yeah, so you think about, you know, a standard Nalgene bottle of water, that's a quart. You're going to have to use one of those bottles for every inch length of cut that the person is. So if a person has a cut that is two inches long, you're going to need two full quarts of water in order to physically flush all the bacteria out of that. That's water under pressure. That's not just

dribbling water out there, so it's a fair amount of water.

Alex Ooley (1:10:49)
Well, that's question I had actually that I didn't ask during the class is if you have an algin, a quart of water, is it enough pressure to just dump it out on the wound or you actually need to be able to have more pressure than that?

Greg (1:10:55)
Mm-hmm.

You need more pressure

than that. You know, the research that's done on this, they used irrigation syringes, which is a big syringe that has kind of a rubber needle on it so it doesn't irritate the wound. the needle diameter is 18 or 19 gauge. So think about squeezing that syringe through a narrow needle.

almost like the pressure that would come out of a squirt gun, something like that. That would be the amount of pressure. something like a hose pressure, running faucet, pressure from a squirt bottle, that's what we're just dumping the water in probably isn't enough to use that formula. It might be able to do it with more than that. If I didn't have any way of creating pressure, I talk about in the class how to.

pop up, punch a hole in the lid of a drinking wattle or cut a little corner of a Ziploc bag or something like that to provide the pressure. But if I didn't have the pressure, maybe more water at a lower pressure might work. There's not a whole lot of research on it, exactly how much you would need at that lower pressure. But if I dump two or three quarts on it at a lower pressure, that's probably going to be enough to physically remove any of that bacteria in the wound.

Alex Ooley (1:11:50)
Mm-hmm.

Yeah, yeah. Okay. So we talked about, obviously, this out of order a little bit. We talked about closing up wounds and talked about glue. Actually, talk about super glue as an effective way to do that. And that's just your standard super glue, right? mean, doctors use, think it was called Derma Bond. But super glue, the actually commercially available super glue or Gorilla Glue also work.

Greg (1:12:35)
Dermabond, yes.

Alex Ooley (1:12:43)
to close up wounds. But one of the things is you don't want to close up a wound before it's been cleaned because then you're just trapping the bacteria, right?

Greg (1:12:53)
Yeah, that's the real dangerous thing. That's the hesitation I get when I talk about any kind of wound closure. People are excited to staple or suture or glue wounds closed. But if you didn't get that wound clean, what you're doing is now closing in a pocket of bacteria into a warm, moist environment where it can thrive and grow.

that bacteria can then start spreading into the blood supply and become a systemic infection if you close it in and allow it to grow that way. So it's really important if you're contemplating any kind of wound closure at all to make sure that that wound is absolutely clean and disinfected before you attempt any type of closure. And if you're not sure it's not clean, it's best not to close it. Cover the wound. We still want to cover it, bandage it, keep it clean.

⁓ not closing and then allow it to heal through granulation or it's called the healing through secondary intention. The tissue grows up from the bottom of the wound up to the top and it'll close on its own. It'll take longer and it'll make a bigger scar but that's a much better outcome than potentially closing in a bunch of bacteria and getting a really serious systemic infection because you didn't get your wound cleaned enough.

Alex Ooley (1:14:06)
Yeah, I think that's far more important than being able to close the wound, right, is to get it clean. So, ⁓ that's the part that people I think tend to overlook the most is how to clean it. those, what, you have water purification tablets. Do you have a preference on the type of tablets that you carry?

Greg (1:14:12)
I agree. agree. Yes.

No doubt.

I do, you know, basically you can get the water purification tablets that come in the form of chlorine or iodine. The chlorine I find works a little bit faster, but the downside of the chlorine is they expire. They have a six month or one year expiration on most of them. They lose potency over time. So you got to replace them a little while, a little bit more. You can use the iodine based wound or water disinfectant.

but it tends to work not so well on more turbid or dirtier water, know, cloudier water, and it takes longer to work than the chlorine. So I tend to use the chlorine. You could use basic bleach if you wanted to use that, you know, eight drops per gallon of basic bleach and clear water will disinfect it. But I use the chlorine-based water purification tablets in my kits, but I replace them every year.

Alex Ooley (1:15:21)
That's something that I hadn't added to my pack that I need to, because I don't go to a lot of places with, you know, like third world countries with dirty water, but I do like to hike a lot. And so if it's in the Grand Canyon or a national park somewhere, you know, having the ability to purify water is incredibly important. So that's the C. So we got through M-A-R-C and we talked.

Greg (1:15:40)
Yep. Yep.

Alex Ooley (1:15:46)
a little bit about H at the beginning. If you don't mind, just sort of go over H one more time if you would for us, the head and hypothermia.

Greg (1:15:54)
Yes,

so the head injury and hypothermia is commonly what we're talking about with the H. With a hypothermia, know, blood clots better when it's warmer. So just general guidelines for all of your patients, keeping them warm, even on a summer day is very useful for traumatic injuries.

So ⁓ getting them out of wet clothes if there's a windy environment or a colder environment will also help keep them warm. So the basic guidelines for treating hypothermia is get them warm and dry however you need to do to get to that point. So get their wet clothes off of them, replace them with dry clothes or dry blankets and get them warmed up. Hot water bottles, chemical heat packs, manual warmth from another person. ⁓

Any of those things are probably good things when your patient is too cold and suffering from hypothermia.

Alex Ooley (1:16:46)
So before we close up and get to the sort of the gear and the sort of preparedness portion at the end of this episode, I want to say a little bit or have you say a little bit about the system collapse medicine portion of your class. If you could say a little bit about why prepare, why do you teach this portion of the class and why do you think it's important for people to understand?

Greg (1:17:07)
You know, what I found over the years of teaching this, and I've been teaching this since 2003. It's been a long time. Talking to lots and lots of students. I get students who are very prepared, disminded, and they want contingencies for every possible emergency, including what happens if I don't have access to a hospital, to my regular doctor.

How do I acquire emergency supply of pharmaceutical drugs that I might need in an emergency if I can't get to the hospital or I can't get to my doctor in a reasonable period of time? And I had so many people looking for that aspect that I decided I think it would be really valuable to talk about what types of pharmaceutical drugs might be useful in those environments.

and how to get those in advance so one could stockpile those meds so that in some emergency, there is some, I generically call it system collapse, if there is no access to a higher level of medical care for whatever reason, either geographically because I'm in some funky country in Africa and there just isn't any emergency care available, or natural disaster, terrorist events,

I'm hiking and I'm three days away from the nearest hospital. It could be any of those environments. I had so many students wanting to know how do I, what do I do in those environments that I added that element to the class.

Alex Ooley (1:18:39)
Yeah. And especially for people who, I I think this is interesting and useful information, even if you don't have any medical condition that requires, you know, daily medication or any kind of regular medication. What if, you know, what if there's some sort of system collapse situation, even if it's just for a week or two weeks and you don't have, you don't even have crazy glue or super glue, right? It may be difficult to go and get those sorts of products.

Even if you don't need a medication of any kind, being prepared for those things ahead of time is useful to think through. But you talk about not only how to get these sorts of medications, but how to get them lawfully and from sources that most people wouldn't even consider ahead of time. What are a couple of the resources that you suggest for this portion of the class?

Greg (1:19:24)
There

are several different options for this and I go into it in pretty good detail in the class. But there are actually doctors that will do, there are kind of prepper doctors that will do video consults with people and sell you a broad variety of antibiotics and various medications that are legit prescription meds from real doctors in the United States.

They'll send them to you by mail order with guidebooks of how to do that. I talk about how to access those types of medical resources. Talk about what are, you know, a lot of foreign countries, the prescription laws are different in foreign countries as compared to the United States. So you have access to various drugs that you can't get over the counter here in a lot of foreign countries.

So I talk about how to bring those back legally into the United States without getting arrested. Talk about some other methods using veterinary drugs, using ⁓ other types of kind of off-label drug use. And some of my classes, I even get into a lot of medical herbalism. And I put a lot of resources. provide each student with a link in my classes that provides medical resources to

books, references as to what types of drugs to types of conditions and dosages and dosing regimens for all of that kind of stuff. And get that information out there and encourage folks that if you have a condition and you anticipate ever being in a situation where you don't have access to the types of drugs that you need.

developing a stockpile of those in a safe and legal manner so that you have some emergency supplies of those drugs should you need them in the event of an emergency.

Alex Ooley (1:21:06)
And I'm glad you mentioned the resources that you make available to the students who take your class. It's what used to be a CD, I guess, that you gave out early on is now is a link that students can download of many of the best resources, I think, that you've compiled over the years. And it covers everything from dentistry to tactical, medical, military manuals and everything in between, essentially, including wilderness medicine and

Greg (1:21:14)
Yes. Yeah. Right.

Alex Ooley (1:21:36)
and other sorts of considerations. great. I mean, think that the resources you make available to download are worth the price of admission to the class ⁓ alone. So, the class is excellent. So that's a great.

Greg (1:21:47)
I think it's pretty

valuable. It's just stuff I've collected. Anything that I've been able to find over the years that I've been able to acquire legally on the internet or anyplace else, I've put into that Dropbox link for people. I think one thing that a lot of the people that come to my classes might really appreciate, one of the file folders in that link that I give all of the students is a collection of older medical textbooks.

know, medical textbooks from the 1850s to 1950s, where they didn't have the same drugs that we did, that we have now. They didn't have the same diagnostic equipment. There were no CAT scans and MRIs. And how did doctors back in the early 1900s diagnose these kind of injuries? I think that might be useful in the event of some type of a collapse in the future.

having to go back to the way we did it 50 or 100 years ago just because we don't have access to that kind of equipment that we rely on on a day-to-day basis now. I think giving students those resources to consult in the event of an emergency, ⁓ longer scale emergency makes a lot of sense to me.

Alex Ooley (1:22:53)
Yeah, and I haven't been through all of these, but there are 12 it looks like ranging from the year 1830 to sort of the mid-early 1900s. So sort of a wide span of time there and certainly I think a lot of wisdom that has been lost at least in the common sense of the modern day. all right. Well, one of questions that I'm sure you get a lot and I know you get in probably every class,

Greg (1:23:12)
Mm-hmm.

Alex Ooley (1:23:20)
every tactical first aid and system collapse medicine class that you teach is where's the gear list? Where do I go to get these things that we've talked about? Can you say a little bit about that?

Greg (1:23:30)
You know, that's probably the most common question I get and my standard answer sounds Sounds a bit dismissive, but if you really think about it, it makes a lot of sense If you need a gear list I say the first thing you need is more training because if you have the training to know What type of gear you need to stop all of these various problems or I solve all these various problems?

You aren't going to need a gear list. If you know how to stop traumatic bleeding, you're going to recognize that you're going to need a couple tourniquets and some pressure bandages and maybe some hemostatic gauze. You're not going to need a separate list for this. Well, I provide a list of what would make a good tactical first aid kit for my students. But I really urge them, if you don't know what you need for a first aid kit,

you probably need more training right off the bat before you get into any kind of list. I don't think the right answer is buying more equipment. We see this in the tactical world all the time. know, people think they can shoot better if they get a gun with a lighter trigger pull or, you know, a heavier weight or whatever the latest and greatest optic is.

That's not the answer. The answer is more practice. And kind of like this, the answer is more knowledge, not more gear. If you don't know what you need, you need more training before we even get to the kit that you might need. But in the class, I provide a good list of all the stuff that you would need for a good tactical first aid kit. Also provide a good list of ⁓ what type of emergency drugs you might consider. But I really urge the students

On top of anything else, get better training because you won't need my list once you know what you have to do to solve all these various problems.

Alex Ooley (1:25:17)
Yeah. And you can start to generate a list just from our conversation here in this podcast, right? I mean, like you said, ⁓ pressure bandages, chest seals, tourniquet, ⁓ crazy glue. Yeah. Yeah. Yeah.

Greg (1:25:22)
Right.

Ternicates hema static buzz crazy glue, you know water purification tablets You're getting all

all the basics, you know for other wound care, you know bandaging supplies and sterile strips and Coban and gauze pads and all of that good stuff is all useful stuff But once you know how to solve the problem, you'll know the gear that you need You don't need my master list, you know, and if there's something on my master list that you have

that you don't know what it's used for, that's kind of useless for you. So I would start with your level of training first and let your training determine what gear you need.

Alex Ooley (1:26:04)
And like you said, you see this in other aspects of the training and tactical world in firearms, for instance. I mean, this was me. I had a bunch of equipment before I ever had any training and I threw most of it away after I got the training. Right? So I found out what I didn't need and there's a common saying and I won't get it exactly right, but I'm sure you've heard it. It's beware of the man with one gun. He might know how to use it. Right? There's some truth to that in this.

Greg (1:26:10)
Yeah. Yeah.

Yeah.

Yeah, yeah exactly.

Alex Ooley (1:26:34)
at area as well. all right, well, Greg, if you would, in closing, ⁓ before we wrap up, tell us a little bit about the other work that you do outside of the Tactical First Aid and System Collapse Medicine class. Say a little bit about your book, if you'd like, the Active Response Training website and what you've got planned for the future.

Greg (1:26:35)
No doubt, no doubt.

Yeah, teaching wise, I teach all kinds of classes. teach various gun classes. I'd say probably, like I said, probably about 40 % of my classes are tactical medicine. And then another 30 % are close quarter shooting classes. So I do really close quarters combatives, gun fights inside of five feet. I'm kind of known for that level of class.

Got some instructor level training on that ⁓ as well. I do knife classes, knife defense classes. I do shotgun classes. ⁓ Do a wide variety of various firearms classes as well. I've been in a lot of demand recently for revolver classes. So I teach some revolver classes as well. So just about any kind of firearms classes I teach, knife stuff and then medical stuff and then.

On top of that, I do a lot of writing for the website that you see on your screen right there. ActiveResponseTraining.net is my website. ⁓ I try to do two to three articles a week, and I have been doing that ever since 2012. So I have 2,100 articles right now up there on the site all for free, covering all kinds of tactical areas, wide variety of subjects there. And then I've got my book, which is a travel guide for dangerous places. ⁓

predominantly third world countries, but could be dangerous places inside the United States as well. And I'm working on several other books as well. ⁓ I've kind of been putting my class schedule on a bit of hold. have cancer, metastasized prostate cancer, and the docs told me I wouldn't have very much longer to live. But ⁓ my tumors are actually growing a lot slower than what the doctors expected, and I'm feeling good. within the next couple of weeks, I'll have

start of a class schedule up for next year. I plan on a full teaching schedule all next year. So, within a couple weeks, look on the website on my classes schedule and you'll see classes all around the country. I think I've taught so far in 13 different states this year and I'll probably do just as many next year too. So, I'll be within driving distance of everybody in the United States somewhere next year for sure.

Alex Ooley (1:29:15)
Yeah, well, that's great news. I'm glad you're doing well and going to be able to continue on with a full schedule next year. I know you take a little bit of a hiatus during the winter, so I hope that's a nice break for you. I you've been really busy, especially in the last few weeks, or at least I think you've been off now for a couple of weeks.

Greg (1:29:26)
Thank you.

Yeah, I did three weeks straight and then I've been off two weeks and then I got two more weeks going I got to teach in Arkansas and Arizona the next couple weeks and then I'm off and I'll be Heading down to South and Central America for the winter. I usually spend the winter in Mexico and the Dominican Republic Doing some writing down there and just relaxing and I won't be teaching again until probably the end of February

Alex Ooley (1:29:58)
Okay. But we'll certainly link to your website so people, if they're interested in taking a class, can keep updated and see your class schedule for next year once it's posted. Again, that's ActiveResponseTraining.net. And I assume you'll be in Arkansas with Ed Monk, right? And then in Arizona at Gunsite.

Greg (1:30:14)
I will, At

Gunsite teaching a revolver class in two weeks, yeah.

Alex Ooley (1:30:19)
Okay, and then what's the class you're doing with Ed Monk?

Greg (1:30:22)
With Ed, I'm doing a close quarter shooting instructor course. So that one's full, two day close quarter instructor course, ⁓ all gun fighting within five feet, how to teach that material. And then GunSight still actually has some ⁓ openings available. It is a huge conference with seven instructors all teaching revolver topics over three days. So it's called the GunSight Patent.

Alex Ooley (1:30:26)
Okay, cool.

Greg (1:30:48)
Pat Rogers Memorial Gun Sight Revolver Roundup. that one still has some openings. The class in Arkansas is full.

Alex Ooley (1:30:57)
Okay. I'll link to the gun site website so that people can check that out if they're interested in attending that class. And then the other, we've talked about your book a few times. I'll link of course to the podcast, re-recorded about your book, but you've also got a website dedicated to your book, ChooseAdventureBook.com. Right?

Greg (1:30:59)
Thank you.

Yeah. Dot com. That's correct.

When the book published in 2020, I was doing a lot of travel blog stuff with that. It didn't prove to be very popular or make me much money, so I've kind of dialed back. And I post a couple articles a month on that site, but there's still

quite a bit of useful travel information on there that's a couple years old. And I updated it a couple times a month. So it's still active, but very few people are interested in third world adventure travel. And it just doesn't make a whole lot of financial sense to spend a whole lot of time writing for that site.

Alex Ooley (1:31:50)
Yeah, well, I found the book to be very interesting and there are a number of lessons in there that are applicable not just to third world adventure travel but to everyday life in the United States as well. So I'd highly recommend it to people even if they don't plan to go to crazy places in Africa or South America.

Greg (1:32:07)
Right. Well,

thank you. Thank you. I think it's useful. It's, you know, it's travel in dangerous places and, you know, many parts of America are becoming dangerous places now. So you don't have to leave the country to necessarily find some utility in some of the recommendations in that book.

Alex Ooley (1:32:17)
That's right.

That's right. I don't have to go far at all to find a dangerous place. ⁓ So even though I live in a rural area. anyway. All right, Greg. Well, thanks a lot for coming along. Is there anything else that you'd like to mention or plug before we close up?

Greg (1:32:26)
Hahaha

No, you covered it. just really appreciate the depth. know, the outline that you produce for this podcast is very impressive. And I like going deep on these subjects. And that's something that many podcasts don't get into. So thank you for willing to take the time and go deep and go beyond the surface level of this material and give people some actual stuff that they can use. So thank you for hosting it.

Alex Ooley (1:32:59)
Yeah, of course. you know, the motivation behind it is, of course, I love to talk with you anytime I get the opportunity, but I did a search and I didn't see that there'd been a podcast recorded on this topic with you. So I thought it was ripe for a discussion. So thank you.

Greg (1:33:15)
Absolutely. I

appreciate it. So thank you.

Alex Ooley (1:33:18)
Yeah, all right. Well, thanks again, Greg, and thanks everybody for tuning in. I hope you enjoyed it. If you did, don't forget to like and subscribe to help us spread the message of freedom. As always, you can find the podcast on YouTube, Rumble, Facebook, and all the most popular podcasting platforms. You can also find us at forgerfreedom.com. Until next time, everybody remember, you are the Forge of Freedom.