WATCHMAN SUITE
MODULE 09
MEDICAL COMMAND
Field Medical Binder
Protocols · Reference · Supplies · Training · Readiness · Medical Assets
© 2026 WATCHMAN Suite, LLC · Patient records excluded by design — print individually from Patient Charts.
◈ TRAUMA PROTOCOLS — GRID DOWN FIELD MEDICINE
These protocols are for use when professional medical care is unavailable. ALWAYS seek modern medical care if accessible. Train with hands-on courses — reading alone is not sufficient preparation.
▶ MARCH PROTOCOL — TACTICAL CASUALTY SEQUENCE▼
MARCH is the tactical order of treatment priorities. Work each phase before moving to the next.
- MASSIVE HEMORRHAGE — Control life-threatening bleeding first. Tourniquet, wound packing, direct pressure. Every second counts.
- AIRWAY — Establish and protect a patent airway. Head-tilt chin-lift, NPA/OPA, intubation, or surgical airway if needed.
- RESPIRATION — Assess breath sounds both sides. Seal open chest wounds. Decompress tension pneumothorax if suspected. Assist ventilations if <8 or >30/min.
- CIRCULATION — Treat shock. IV/IO fluids if trained. Monitor pulse, BP, mental status. Maintain systolic >90 mmHg.
- HYPOTHERMIA / HEAD INJURY — Wrap patient immediately — hypothermia kills trauma patients. Assess GCS. Elevate head 30° if head injury and no spinal concern.
CARE UNDER FIRE: The ONLY treatment during active fire is tourniquet HIGH AND TIGHT on bleeding extremity. Move to cover FIRST, then treat. Fire superiority is the best medicine on the battlefield.
PRIMARY SURVEY — ABCDE: A = Airway (with C-spine control) • B = Breathing (look, listen, feel) • C = Circulation (hemorrhage, pulse, BP) • D = Disability (GCS, pupils) • E = Expose (remove clothing, check all surfaces, prevent hypothermia)
▶ MASSIVE HEMORRHAGE CONTROL▼
Uncontrolled hemorrhage is the #1 preventable cause of death. Act immediately. The golden hour begins now.
STEP 1 — DIRECT PRESSURE
- Don nitrile gloves. Grab a bandanna or cloth if no gloves available — never touch wound with bare hand.
- Apply firm, direct pressure to the wound using gauze pads or any clean cloth.
- If limb wound, elevate the extremity above the level of the heart while maintaining pressure.
- Maintain pressure for a full 5–10 minutes without peeking. If blood soaks through, add more gauze on top — do NOT remove first layer.
- If direct pressure slows but does not stop bleeding, locate the pressure point for that region and compress.
KEY PRESSURE POINTS: Brachial artery (mid-upper arm) for arm wounds; Femoral artery (groin crease) for thigh wounds; Popliteal artery (back of knee) for lower leg wounds.
STEP 2 — TOURNIQUET (Extremity Only)
Apply tourniquet when: Direct pressure fails, arterial (spurting) bleeding, amputation, or you are alone and cannot maintain pressure.
- Place tourniquet 2–3 inches above the wound (not over a joint). For amputations or unclear wound location, apply high and tight — as high as possible on the limb.
- Apply CAT tourniquet: thread limb through loop, tighten strap, twist windlass until bleeding stops and distal pulse is absent.
- Lock the windlass in the clip. Secure the strap over the windlass.
- WRITE THE TIME on the tourniquet AND on the patient's forehead. Time on tourniquet determines risk of limb loss.
- Improvised tourniquet: use a 2–3" wide cloth (belt, bandanna, cravat). Tie around limb, insert a stick, pencil, or pen, twist until bleeding stops. Tie stick in place.
- Check the wound at 10-minute intervals. If natural clotting has occurred, release pressure gradually — leave tourniquet in place within reach.
Tourniquet risks: Limb loss after 1–2 hours. Toxic buildup in extremity releases into core upon removal. Do not remove in the field if more than 2 hours applied. Note time — inform any medical personnel.
STEP 3 — WOUND PACKING (Junctional / Non-Compressible)
Use for wounds that cannot be tourniqueted: groin, armpit, neck, shoulder (junctional areas). Also for large lacerations requiring packing.
- Open QuikClot or Celox hemostatic gauze. Note: Celox is chitosan-based — avoid if patient has severe shellfish allergy.
- Pack the gauze DIRECTLY into the wound, as deep as possible, aiming for the bleeding source. Use your finger to push gauze firmly into the wound cavity.
- Continue packing until the wound is filled with gauze. Do not just lay gauze on top — it must be packed in.
- Apply firm manual pressure for a minimum of 3–5 minutes (QuikClot) or 3 minutes (Celox). Do not release early.
- Apply an Israeli Battle Dressing or pressure bandage over the packed wound to maintain pressure.
- If bleeding restarts, do NOT remove existing packing. Add more gauze on top and reapply pressure.
Direct pressure and gauze packing are your first line. Hemostatic agents (QuikClot/Celox) are second line when standard gauze alone fails. Hemostatic agents shelf life: ~3 years; store away from sunlight.
BLOOD LOSS ASSESSMENT
Adult body contains ~10 pints (5 liters) of blood:
• <1.5 pints: Little effect, patient may be asymptomatic
• 1.5–3.5 pints: Rapid heart rate, rapid breathing, pale skin, patient very agitated
• 3.5–4 pints: BP drops, patient confused, very rapid heartbeat
• >4 pints: Very pale, possibly unconscious, dropping heart rate — CRITICAL
• <1.5 pints: Little effect, patient may be asymptomatic
• 1.5–3.5 pints: Rapid heart rate, rapid breathing, pale skin, patient very agitated
• 3.5–4 pints: BP drops, patient confused, very rapid heartbeat
• >4 pints: Very pale, possibly unconscious, dropping heart rate — CRITICAL
▶ AIRWAY MANAGEMENT▼
CONSCIOUS PATIENT — CHOKING / OBSTRUCTION
- Ask: "Are you choking?" If they can speak, airway is partially open. Encourage coughing. Do not intervene yet.
- If complete obstruction (cannot speak, holding throat, nodding yes): Perform Heimlich maneuver — stand behind patient, make fist above belly button, wrap other arm around patient, thrust sharply upward and inward. Repeat until object dislodged.
- If patient loses consciousness: lay flat, straddle hips, give upward abdominal thrusts with heel of palm. Check mouth after each attempt.
- INFANT: Place face-down over forearm, give 5 back blows with heel of hand to upper back. Alternate with 5 chest thrusts. Never do abdominal thrusts on infant.
UNCONSCIOUS PATIENT — AIRWAY POSITIONING
- Head-Tilt Chin-Lift: Tilt head back, grasp underside of chin and jaw, lift to straighten airway. Use only when NO suspected spinal injury.
- Jaw Thrust (spinal precaution): Without tilting head, place fingers behind the angles of the jaw and thrust jaw forward. Use when spinal injury suspected.
- Insert oral airway (OPA) if available: size from corner of mouth to earlobe. Insert upside-down in adults, rotate 180° once past teeth. Insert right-side up in children.
- Insert nasal airway (NPA) if patient has gag reflex (cannot tolerate OPA): measure from nostril to earlobe, lubricate, insert straight back along floor of nasal passage.
- Place unconscious breathing patient in RECOVERY POSITION: on their side, top leg bent forward for stability, head tilted slightly back, mouth down to drain vomit.
EMERGENCY CRICOTHYROIDOTOMY (Last Resort Only): For complete, unrelievable obstruction when Heimlich has failed and patient cannot breathe. Locate Adam's apple, move 1 inch below to cricoid cartilage. Make small horizontal incision in the crease between them. Insert hollow tube (straw, pen casing). Perform CPR rescue breaths through tube if needed. ONLY when patient will otherwise die in minutes.
▶ CPR — CARDIOPULMONARY RESUSCITATION▼
CPR is most effective for: airway obstruction, hypothermia, anaphylaxis, near-drowning, lightning strike. It is of limited value for cardiac arrest from heart disease in grid-down. TRAIN IN PERSON — reading is not enough.
ADULT / CHILD CPR
- Verify scene safety. Check responsiveness: shake shoulders, call loudly "Are you OK?"
- Check for pulse (carotid — neck) and breathing simultaneously for no more than 10 seconds.
- No pulse, not breathing (or only gasping): Position patient flat on back on firm surface.
- COMPRESSIONS: Place heel of hand on center of chest (lower half of sternum, nipple level). Second hand on top, fingers interlaced. Lock elbows, compress straight down 2 inches (adult) or 1.5 inches (child). Release fully.
- Rate: 100–120 compressions per minute. Count aloud to maintain rhythm ("1-and-2-and-3..."). Use "Stayin' Alive" tempo as a mental guide.
- After 30 compressions, open airway with head-tilt chin-lift. Give 2 rescue breaths (1 second each, watch chest rise). Pinch nose closed for mouth-to-mouth.
- Continue 30:2 cycles. Reassess after 5 cycles (2 minutes). Continue until patient responds, trained help arrives, or 30 minutes without result (pupils dilated and fixed = cessation appropriate).
COMPRESSION-ONLY CPR: If untrained or unwilling to give rescue breaths, continuous compressions at 100/min still provide significant benefit. Better than nothing.
INFANT CPR: Use 2 fingers for compressions, compress 1.5 inches. Ratio 30:2 with 1 rescuer, 15:2 with 2 rescuers. Cover both nose and mouth for rescue breaths.
AED: If available, use immediately. Turn on, attach pads per diagram, follow prompts. Do not touch patient during shock. Resume CPR immediately after shock.
▶ BURN INJURIES▼
BURN CLASSIFICATION
1st Degree (Superficial): Redness, pain, no blistering. Epidermis only. Treat: cool water, aloe vera, OTC pain relief.
2nd Degree (Partial Thickness): Blisters, intense pain, weeping, red/mottled. Epidermis + dermis. Treat: cool water, sterile dressing, do NOT pop blisters.
3rd Degree (Full Thickness): White, brown or black, leathery, may be painless (nerve destruction). All skin layers. Treat: cover sterile dressing, NO cool water (hypothermia risk if large area), urgent care needed.
Inhalation Injury: Singed eyebrows/nasal hair, hoarse voice, soot in mouth. Airway swells — URGENT. Cool moist air, monitor airway closely.
2nd Degree (Partial Thickness): Blisters, intense pain, weeping, red/mottled. Epidermis + dermis. Treat: cool water, sterile dressing, do NOT pop blisters.
3rd Degree (Full Thickness): White, brown or black, leathery, may be painless (nerve destruction). All skin layers. Treat: cover sterile dressing, NO cool water (hypothermia risk if large area), urgent care needed.
Inhalation Injury: Singed eyebrows/nasal hair, hoarse voice, soot in mouth. Airway swells — URGENT. Cool moist air, monitor airway closely.
TREATMENT PROTOCOL
- Stop the burning: remove patient from source. Remove clothing and jewelry from burned area (unless fused to skin).
- Cool the burn: run cool (NOT ice cold) water over burn for 20 minutes. For large burns (>20% body surface), limit cooling to prevent hypothermia.
- Do NOT apply butter, oil, toothpaste, or other home remedies — increases infection risk.
- Do NOT pop blisters — they are natural sterile barriers.
- Cover with clean, non-stick dressing. Wet sterile gauze works well. Wrap loosely.
- For 2nd/3rd degree burns: change dressing twice daily with dilute Betadine (1:10 with water) or sterile saline.
- Aloe vera (fresh gel from leaf) is an effective natural treatment for 1st and mild 2nd degree burns.
- Natural burn treatments: raw honey as antimicrobial dressing, lavender essential oil diluted in carrier oil for minor burns.
- Monitor for infection: increasing redness, warmth, swelling, foul odor, fever = begin antibiotics (Amoxicillin or Doxycycline).
Burns >20% body surface = HIGH risk of shock and fluid loss. Push oral fluids aggressively. Burns to face/neck/hands/genitals require priority treatment.
▶ FRACTURES, DISLOCATIONS & SPRAINS▼
FRACTURE IDENTIFICATION
Signs of fracture: Severe pain and tenderness, swelling and bruising, abnormal deformity or angulation, loss of normal function, crepitus (grating sensation), abnormal motion.
Fracture types: Stable (aligned), Open/Compound (bone through skin — HIGH infection risk), Comminuted (shattered), Greenstick (partial break, children).
Fracture types: Stable (aligned), Open/Compound (bone through skin — HIGH infection risk), Comminuted (shattered), Greenstick (partial break, children).
SPLINTING PROTOCOL
- Check CMS BEFORE and AFTER splinting: Circulation (pulse beyond wound site, capillary refill <2 sec), Motor (can patient move fingers/toes?), Sensation (can patient feel touch beyond injury?).
- Do NOT attempt to straighten a fractured bone unless circulation is absent (pulseless extremity). If pulse is absent, gentle traction may be necessary to restore flow.
- Splint in position of comfort (or the position found). Splint should immobilize the joint ABOVE and BELOW the fracture.
- SAM splint: mold to body contour, pad bony prominences, secure with elastic bandage or strips of cloth. If none available, use straight sticks, branches, a rolled magazine — pad them first.
- Apply firmly enough to prevent movement but not so tight as to cut circulation. Ensure fingers/toes are visible to monitor.
- Elevate the injured extremity above heart level to reduce swelling.
- Open fracture: rinse wound thoroughly with sterile water or dilute Betadine (1:10). Cover exposed bone with wet sterile dressing. Do NOT push bone back in. Splint as found. Begin antibiotics immediately (Amoxicillin 500mg TID).
DISLOCATIONS
- Check CMS. Shoulder, finger, kneecap, and ankle are most common dislocations in field settings.
- Reduction (only if trained): gentle, steady traction along the axis of the limb while assistant stabilizes the proximal segment. Do NOT jerk or force.
- If unable to reduce: splint in position found and transport. Successful reduction restores pulse — recheck CMS immediately after.
- After reduction: apply ice (if available), sling or splint, rest.
SPRAINS
RICE protocol: Rest, Ice (20 min on/20 min off for first 48 hrs), Compression (elastic bandage), Elevation. Ibuprofen 400-600mg every 6-8 hours for swelling/pain.
▶ HYPOTHERMIA & COLD INJURIES▼
HYPOTHERMIA STAGES
Mild (96–90°F / 35–32°C): Shivering (body's warming mechanism — a GOOD sign), poor coordination, slurred speech, confusion begins.
Moderate (90–82°F / 32–28°C): Shivering STOPS (dangerous — body can no longer warm itself), muscle rigidity, severe confusion, drowsy.
Severe (<82°F / <28°C): Unresponsive, rigid muscles, barely perceptible pulse. May appear dead. "Not dead until warm and dead."
Moderate (90–82°F / 32–28°C): Shivering STOPS (dangerous — body can no longer warm itself), muscle rigidity, severe confusion, drowsy.
Severe (<82°F / <28°C): Unresponsive, rigid muscles, barely perceptible pulse. May appear dead. "Not dead until warm and dead."
TREATMENT PROTOCOL
- Move patient to shelter and out of wind, rain, and cold. Handle gently — rough handling can trigger ventricular fibrillation in severe hypothermia.
- Remove wet clothing carefully. Replace with dry insulation. Wrap in sleeping bag, blankets, emergency space blanket (reflective side in).
- Protect from ground conduction — always put insulation UNDER the patient (as much heat is lost to ground as to air).
- Warm the CORE first: focus heat to armpits, groin, and neck (major blood vessel locations). Use warm water bottles, chemical heat packs, or body heat. Wrap in insulation, not direct high heat.
- For mild hypothermia with active shivering: warm sweet liquids (hot cocoa, warm broth). No alcohol.
- For moderate/severe: NO oral fluids (aspiration risk). Passive rewarming only unless warm IV saline available.
- Monitor breathing. Severe hypothermia — if no pulse or breathing, begin CPR. Continue until patient is rewarmed to at least 86°F (30°C) before calling cessation.
- Do NOT rub extremities (releases cold blood from periphery to core too rapidly).
FROSTBITE
- Do NOT rewarm if there is any chance of refreezing — a thawed and refrozen extremity suffers far worse damage than frozen tissue.
- Rewarm in warm water (100–105°F / 38–41°C) for 20–40 minutes. Protect from direct heat. Very painful — give pain relief.
- Do NOT rub frostbitten tissue. Do not walk on frostbitten feet unless no alternative. Cover with clean, dry dressings.
- Blisters are protective — do not pop. Elevate extremity. Watch for infection.
▶ HEAT ILLNESS — EXHAUSTION & HEAT STROKE▼
RECOGNITION — THE SPECTRUM
Heat Cramps: Painful muscle spasms during/after exertion. Sweating normal, mental status normal. Salt and water depletion.
Heat Exhaustion: Heavy sweating, weakness, headache, nausea, dizziness, pale clammy skin. Temp may reach 104°F. Mental status NORMAL — patient answers questions appropriately.
HEAT STROKE (KILLS): ALTERED MENTAL STATUS — confusion, combativeness, slurred speech, seizure, or unconsciousness — in a hot patient. Skin may be dry OR still sweating. Temp typically >104°F. This is a true emergency: brain cells are cooking.
Heat Exhaustion: Heavy sweating, weakness, headache, nausea, dizziness, pale clammy skin. Temp may reach 104°F. Mental status NORMAL — patient answers questions appropriately.
HEAT STROKE (KILLS): ALTERED MENTAL STATUS — confusion, combativeness, slurred speech, seizure, or unconsciousness — in a hot patient. Skin may be dry OR still sweating. Temp typically >104°F. This is a true emergency: brain cells are cooking.
The dividing line is the BRAIN. Any altered mental status in a heat casualty = heat stroke. Treat immediately — minutes of delay determine survival and permanent brain/kidney damage. COOL FIRST, EVACUATE SECOND.
TREATMENT — HEAT EXHAUSTION
- Stop all activity. Move to shade or the coolest available space. Remove excess clothing.
- Lay patient down, elevate legs slightly.
- Oral fluids with electrolytes (ORS, diluted sports drink). Plain water alone is acceptable but salt is needed — add ¼ tsp salt per quart if no ORS.
- Evaporative cooling: wet the skin, fan aggressively. Cool wet cloths to neck, armpits, groin.
- No return to work/exertion the same day. Untreated heat exhaustion progresses to heat stroke.
TREATMENT — HEAT STROKE (AGGRESSIVE COOLING)
- Cool NOW by the fastest means available. Best: whole-body cold water immersion (creek, stock tank, tub) with head supported. Target: cool until mental status improves or shivering begins.
- No immersion available: strip, soak with water, fan continuously, and place ice/cold packs at neck, armpits, and groin. Rotate wet sheets.
- NOTHING BY MOUTH while mental status is altered — aspiration risk. Do NOT give ibuprofen, acetaminophen, or aspirin — antipyretics do not work on heat stroke and add liver/kidney injury.
- Protect the airway; recovery position if vomiting. Treat seizures by protecting the patient from injury.
- Once alert: small sips of ORS. Monitor closely for 24–48 hrs — kidney injury and rebound hyperthermia are common. Dark or absent urine is a red flag.
PREVENTION: Work/rest cycles in heat (15 min rest per 45 min work above 85°F, more when humid), drink to thirst plus salted food, acclimatize new workers over 7–10 days, and never leave anyone in a closed vehicle or structure. Highest risk: elderly, children, and anyone on the second consecutive day of heavy work in heat.
▶ SHOCK MANAGEMENT▼
Shock is life-threatening organ failure due to inadequate blood flow. Treat the CAUSE first, then manage the symptoms.
SHOCK TYPES
Hemorrhagic: Blood loss — most common trauma shock. Control bleeding first.
Hypovolemic: Fluid loss (dehydration, burns, vomiting/diarrhea).
Anaphylactic: Severe allergic reaction. Epinephrine immediately.
Septic: Severe infection. Antibiotics, fluids.
Neurogenic: Spinal cord injury. Warm patient, fluids.
Hypovolemic: Fluid loss (dehydration, burns, vomiting/diarrhea).
Anaphylactic: Severe allergic reaction. Epinephrine immediately.
Septic: Severe infection. Antibiotics, fluids.
Neurogenic: Spinal cord injury. Warm patient, fluids.
SIGNS OF SHOCK
Pale, cool, clammy skin ("cold and clammy") • Rapid weak pulse (>100 bpm) • Rapid shallow breathing (>20/min) • Low BP (systolic <90 mmHg) • Altered mental status: anxious → confused → unresponsive • Capillary refill >2 seconds
TREATMENT PROTOCOL
- Control all hemorrhage first. Nothing else matters while blood is pouring out.
- Lay patient flat. Elevate legs 12 inches above heart level (the "shock position") unless head injury or chest injury suspected.
- Maintain body temperature — cover with blankets. Hypothermia dramatically worsens shock outcomes.
- If conscious and no abdominal/chest injury: push oral fluids (water, oral rehydration solution — 200–400 mL/hr).
- If IV capable: NS (0.9% NaCl) or Lactated Ringer's (LR preferred for large-volume resuscitation). Target systolic >90 mmHg. Do NOT over-hydrate — "permissive hypotension" in penetrating trauma: target systolic 80–90, not normal.
- Monitor mental status, pulse, and respirations every 5 minutes. Any deterioration = escalate treatment.
- Do NOT give food or drink if abdominal injury suspected. Do NOT give aspirin or ibuprofen (increase bleeding).
FLUID RESUSCITATION — BY SHOCK CLASS (SOF MEDIC PROTOCOL)
| CLASS | BLOOD LOSS | PULSE | BP | FLUID ACTION |
|---|---|---|---|---|
| I | <750 mL / <15% | <100 | Normal | Oral fluids. No IV required unless prolonged. |
| II | 750–1500 mL / 15–30% | 100–120 | Normal/low | 1L NS or LR IV bolus over 30 min. Reassess. Oral ORS if no IV. |
| III | 1500–2000 mL / 30–40% | >120 | Dropping | 2L NS/LR wide open. Reassess after each liter. Urgent evacuation. |
| IV | >2000 mL / >40% | >140 or absent | Critical | Maximum IV rate. Field blood transfusion if trained/available. Survival unlikely without surgical intervention. |
PERMISSIVE HYPOTENSION: In penetrating trauma with ongoing hemorrhage, target systolic BP 80–90 mmHg — NOT normal. Aggressive fluids before hemorrhage is controlled dilute clotting factors and worsen bleeding. Control the bleed first. This does NOT apply to head injuries — maintain systolic >100 for brain perfusion.
▶ ANAPHYLAXIS — SEVERE ALLERGIC REACTION▼
Anaphylaxis is a medical emergency. Death can occur within minutes from airway obstruction or cardiovascular collapse.
SIGNS: Hives/rash, swelling (face, throat, tongue), difficulty breathing/wheezing, drop in blood pressure, rapid pulse, nausea/vomiting, sense of doom. Can follow insect stings, food (shellfish, nuts), medications.
- EPINEPHRINE IMMEDIATELY: Inject EpiPen (0.3mg epinephrine 1:1000) into outer mid-thigh (through clothing if needed). Children <66 lbs: use EpiPen Jr (0.15mg). Hold for 10 seconds.
- Call for help / prepare to transport. Epinephrine is temporary — patient needs definitive care.
- Position: if breathing difficulty, allow patient to sit up. If low BP/shock, lay flat with legs elevated.
- Give Diphenhydramine (Benadryl) 50mg orally — supports Epinephrine but NOT a substitute.
- For wheezing: albuterol inhaler if available (2–4 puffs).
- Repeat Epinephrine in 5–15 minutes if symptoms not improving. A second EpiPen may be required.
- Begin CPR immediately if patient loses pulse or stops breathing. CPR can be successful in anaphylaxis with epinephrine on board.
- Monitor for 4–8 hours — biphasic reactions can recur hours later.
▶ SNAKEBITE — PIT VIPER (COPPERHEAD / RATTLESNAKE)▼
Southern Appalachian AO species: copperhead (most bites, rarely fatal) and timber rattlesnake (more potent, can be life-threatening). Both are pit vipers — triangular head, vertical pupils, heat pits. ~25% of pit viper bites are "dry" (no venom injected), but you cannot assume this in the field.
FIELD TREATMENT — WHAT TO DO
- Move the patient away from the snake. Do NOT attempt to catch or kill it — a photo from distance is enough, and dead snakes can still envenomate reflexively.
- Keep the patient calm and STILL. Physical exertion pumps venom through the lymphatics. Carry them if evacuation is possible.
- Remove rings, watches, and tight clothing from the bitten limb NOW — before swelling makes it impossible.
- Immobilize the limb with a splint or sling, positioned at roughly heart level. Do not raise above the heart (speeds venom spread) or hang far below (worsens local swelling).
- Mark the leading edge of swelling with a pen and WRITE THE TIME. Re-mark every 15–30 minutes — the progression rate tells you how bad the envenomation is.
- Wash the wound with soap and water, cover with a clean dressing.
- If ANY modern care is reachable, evacuate — antivenom is the only definitive treatment for serious envenomation, and it is a hospital drug. Rapid swelling, bleeding from gums, metallic taste, or difficulty breathing = evacuate at any cost.
THE DO-NOTS (ALL PROVEN HARMFUL)
Do NOT cut the wound. Do NOT suck venom or use commercial suction kits — they remove no meaningful venom and destroy tissue. Do NOT apply a tourniquet or tight constriction band — concentrating pit viper venom in a limb destroys the limb. Do NOT apply ice — worsens local tissue damage. Do NOT give alcohol. Pain control: acetaminophen ONLY — no ibuprofen or aspirin (venom already impairs clotting).
GRID-DOWN MONITORING (NO ANTIVENOM AVAILABLE)
- Serial vitals q15–30 min on the flowsheet. Watch BP and pulse — hypotension signals systemic envenomation.
- Watch for coagulopathy: bleeding gums, blood in urine, spreading bruising away from the bite.
- Push oral fluids to protect the kidneys. Treat pain, keep the limb splinted, keep the patient down.
- Copperhead bites in healthy adults usually resolve with supportive care over days — expect severe swelling and pain. Rattlesnake bites with rapid progression are life-threatening without antivenom; supportive care and fluids are the only field tools.
- Days later: watch the bite site for infection and necrosis; debride dead tissue and treat per the infected wound protocol.
PREVENTION: Boots and long pants in brush, never place hands where you cannot see (rock crevices, woodpiles), use a light at night, and step ON logs, not over them. Most bites occur handling or harassing the snake.
▶ HEAD INJURIES▼
Head injuries can deteriorate rapidly and without warning. Frequent monitoring is mandatory.
ASSESSMENT — AVPU SCALE
Alert — fully awake and oriented
Voice — responds to verbal commands
Pain — only responds to painful stimulus
Unresponsive — no response to any stimulus
Voice — responds to verbal commands
Pain — only responds to painful stimulus
Unresponsive — no response to any stimulus
DANGER SIGNS — SEEK/ESCALATE CARE IMMEDIATELY
• Pupils unequal in size, or not reacting to light (suggests brain herniation)
• Loss of consciousness, or worsening level of consciousness
• Severe headache that is progressively worsening
• Repeated vomiting
• Seizures
• Clear fluid from ears or nose (indicates skull fracture)
• "Battle's sign" — bruising behind ear (suggests basilar skull fracture)
• Loss of consciousness, or worsening level of consciousness
• Severe headache that is progressively worsening
• Repeated vomiting
• Seizures
• Clear fluid from ears or nose (indicates skull fracture)
• "Battle's sign" — bruising behind ear (suggests basilar skull fracture)
TREATMENT
- ABC first — ensure airway is open, patient is breathing, no major bleeding.
- Assume spinal injury with all significant head injuries. Use jaw thrust for airway. Log-roll for repositioning.
- Elevate head of bed/patient 30 degrees to reduce intracranial pressure — only if no spinal injury concerns OR secured to backboard.
- Pain: Acetaminophen ONLY (325–1000mg). NO aspirin or ibuprofen — these increase bleeding risk.
- Place vomiting patient in lateral recumbent (recovery) position while maintaining spinal precautions.
- Monitor AVPU every 15 minutes. Document any change — deterioration is the key warning sign.
- Monitor pupils: check reactivity to light every 30 minutes. Unequal or non-reactive pupils = emergency.
- Keep patient awake for first 4–6 hours if concussion suspected. After that, sleep is acceptable — check responsiveness every 2 hours.
- Do NOT give fluids excessively — can worsen brain swelling.
▶ WOUND CARE & INFECTION MANAGEMENT▼
WOUND IRRIGATION
- After bleeding is controlled: irrigate aggressively with sterile (boiled and cooled) water using a syringe or bulb syringe for pressure. "The solution to pollution is dilution."
- First irrigation: dilute Betadine (1 part Betadine to 10 parts water) or Dakin's solution is acceptable.
- Subsequent irrigations: plain sterile water — concentrated antiseptics damage new cells and slow healing.
- Remove visible debris, dirt, and foreign material with gloved fingers or tweezers. Assume all wounds are dirty.
WOUND CLOSURE DECISION
Close (Primary Intention): Clean, fresh wounds (<6 hours old), low-tension, no signs of infection. Smaller scar but higher infection risk.
Leave Open (Secondary Intention): Bite wounds, dirty/contaminated wounds, puncture wounds, wounds >6 hours old, any signs of infection. Larger scar but safer. Granulation tissue fills in naturally.
RULE: When in doubt — leave it open. Infection in a closed wound is far more dangerous than an open wound healing slowly.
Leave Open (Secondary Intention): Bite wounds, dirty/contaminated wounds, puncture wounds, wounds >6 hours old, any signs of infection. Larger scar but safer. Granulation tissue fills in naturally.
RULE: When in doubt — leave it open. Infection in a closed wound is far more dangerous than an open wound healing slowly.
DRESSING CHANGES
- Change dressings minimum twice daily, or whenever saturated.
- Apply wet-to-dry dressing for open wounds: wet clean gauze with sterile water, wring out, apply to wound. Cover with dry outer dressing.
- Triple antibiotic ointment (Neosporin/bacitracin) at wound edges — NOT inside deep wounds.
INFECTION SIGNS — ESCALATE ANTIBIOTICS
Increasing redness spreading from wound • Warmth • Swelling • Pus or foul-smelling discharge • Red streaking spreading up limb (cellulitis/sepsis) • Fever (>100.4°F) • Swollen lymph nodes
Red streaking up limb = potential blood poisoning (sepsis). This is life-threatening. Begin antibiotics immediately: Amoxicillin 500mg TID or Doxycycline 100mg BID for 7–10 days.
Red streaking up limb = potential blood poisoning (sepsis). This is life-threatening. Begin antibiotics immediately: Amoxicillin 500mg TID or Doxycycline 100mg BID for 7–10 days.
DAKIN'S SOLUTION (Field Antiseptic)
Dissolve ½ tsp baking soda in 4 cups boiled water. Add bleach per desired strength: 3 tsp = mild (clean wounds), 3 tbsp = moderate (infected wounds). Store in dark container at room temperature. Make fresh every 2–3 days — loses potency quickly.
▶ TENSION PNEUMOTHORAX & OPEN CHEST WOUNDS▼
Tension pneumothorax is rapidly fatal. It is a clinical diagnosis — do NOT wait for confirmation. Treat based on signs.
RECOGNIZE — TENSION PNEUMOTHORAX
Mechanism: Penetrating or blunt chest trauma → air enters pleural space → lung collapses → pressure builds → heart and great vessels shift away (mediastinal shift) → drops venous return → cardiac arrest.
Signs (MATCH): Absent breath sounds on injured side • Tracheal deviation AWAY from injury (late sign) • Respiratory distress — severe, worsening • Cyanosis • Hypotension despite fluid
Rule: If penetrating chest trauma + respiratory distress + decreased breath sounds on one side = decompress immediately.
Signs (MATCH): Absent breath sounds on injured side • Tracheal deviation AWAY from injury (late sign) • Respiratory distress — severe, worsening • Cyanosis • Hypotension despite fluid
Rule: If penetrating chest trauma + respiratory distress + decreased breath sounds on one side = decompress immediately.
NEEDLE DECOMPRESSION (Tension Pneumothorax)
- Identify the affected side — no breath sounds, patient deteriorating. If unsure: decompress the side of injury.
- Landmark: 2nd intercostal space (ICS), midclavicular line (MCL). Find the clavicle, go 2 ribs down, at the midpoint of the clavicle.
- Prep skin with Betadine or alcohol wipe if time permits. Glove up.
- Insert a 14-gauge (or largest available) IV catheter-over-needle PERPENDICULAR to the chest wall, immediately ABOVE the 3rd rib (to avoid the neurovascular bundle running under each rib).
- A rush of air = correct placement. Tension is relieved. Advance catheter, remove needle. You will hear/feel the pressure release.
- Leave catheter in place — do NOT remove. Attach a 3-way stopcock or finger of a glove with a hole cut in the tip (one-way valve) to prevent re-accumulation.
- Reassess breath sounds and vital signs immediately. Patient should improve within seconds to minutes.
- This is a bridge — patient needs a chest tube as soon as possible. Evacuate urgently.
If no large-bore IV catheter: a 16–18 gauge will work but may kink. A 3.5" or longer needle is required for obese or muscular patients — standard 1.5" may not reach pleural space.
OPEN CHEST WOUND (Sucking Chest Wound)
Any chest wound larger than 2 cm that makes a sucking or bubbling noise with breathing. Air enters through the wound instead of through the airway — lung collapses. Risk of converting to tension pneumothorax.
- Apply a vented chest seal (Hyfin or Bolin) directly over the wound. Remove packaging, dry skin first — seal must be airtight. Center over wound.
- Vented seals allow air OUT but not IN — this prevents tension buildup. Commercial preferred; improvise if unavailable.
- Improvised chest seal: petroleum gauze or plastic wrap (from an MRE bag, IV bag, or wrapper) taped on THREE sides only — leave one side open to vent. Check: does it flutter out on exhale? Good.
- If patient deteriorates after sealing (increasing respiratory distress, dropping BP) — LIFT one edge of the seal to release pressure. This indicates tension pneumothorax is building. Proceed to needle decompression.
- If exit wound present: seal BOTH entry and exit wounds.
- Place patient in position of comfort — sitting up or semi-reclined if breathing is easier that way.
- Monitor continuously. Evacuate urgently.
▶ PRIMARY & SECONDARY SURVEY — PATIENT ASSESSMENT▼
Perform in this exact order on every trauma patient. Primary Survey identifies life threats. Secondary Survey finds everything else. Do not proceed to secondary until primary threats are controlled.
PRIMARY SURVEY — ABCDE (Life Threats Only)
- AIRWAY with C-spine control. Is airway open and clear? Can patient speak? Gurgling = fluid, needs suctioning. Stridor = partial obstruction. If unconscious: chin-lift (no trauma) or jaw thrust (trauma). Insert OPA/NPA. Intubate or cric if needed.
- BREATHING. Look: chest rise — symmetric? Wounds? Look, listen, feel. Rate and depth. Absent breath sounds one side = pneumothorax. Seal open wounds. Decompress tension pneumo. Assist ventilations if <8 or >30 breaths/min.
- CIRCULATION. Control all external hemorrhage NOW — tourniquet, wound packing, pressure. Check radial pulse: rate, quality, present/absent. Capillary refill (normal <2 sec). Skin: pale, cool, clammy = shock. Estimate blood loss. Start IV/IO if trained.
- DISABILITY. Rapid neurological assessment. AVPU: Alert, Voice, Pain, Unresponsive. Pupils: equal and reactive? Glasgow Coma Scale if time. Any limb weakness or paralysis?
- EXPOSE / ENVIRONMENT. Cut away clothing — look at entire body. Back, armpits, groin, scalp. Find EVERY wound. Cover with blanket immediately after — prevent hypothermia.
Treat life threats AS YOU FIND THEM — do not complete the survey before acting. Airway before breathing before circulation. But a tourniquet applied in seconds before the survey is always correct for exsanguinating extremity hemorrhage.
SECONDARY SURVEY — HEAD TO TOE
Only begin after primary threats are controlled. Systematic head-to-toe exam to find all injuries.
- HEAD: Scalp — feel for lacerations, depressions, boggy areas. Pupils equal and reactive. Ears — blood or CSF fluid (clear). Battle's sign behind ear (bruising = basilar skull fracture, late). Mouth — airway clear, teeth intact.
- NECK: Tracheal position — midline? Midline deviation = tension pneumo or large hematoma. Jugular veins — distended? (tension pneumo, tamponade). Cervical spine tenderness — maintain precautions if suspected.
- CHEST: Feel every rib — crepitus, step-off, tenderness. Auscultate both sides. Look for paradoxical movement (flail chest). Bruising, seat belt marks.
- ABDOMEN: Gently palpate all four quadrants. Rigid = blood/peritonitis. Guarding. Bruising (especially flank — kidney/spleen). Do NOT repeat palpation — once is enough.
- PELVIS: Compress inward on both iliac crests once only. Movement or pain = pelvic fracture (life-threatening hemorrhage). Do NOT repeatedly rock — worsens bleeding.
- EXTREMITIES: Palpate long bones for fracture. Check CMS (Circulation/Motor/Sensation) distal to each injury. Deformity, swelling, crepitus. Log-roll patient — check entire back, buttocks, posterior thighs.
- REASSESS: Repeat primary survey after secondary. Patient status changes. Document all findings and times.
▶ SURGICAL AIRWAY — CRICOTHYROIDOTOMY▼
Last-resort airway. Perform when: cannot intubate, cannot ventilate, complete airway obstruction unrelieved by Heimlich. Death in minutes without action. Two methods: Needle (faster, temporary) and Surgical (definitive field airway).
ANATOMY LANDMARK
Feel the Adam's apple (thyroid cartilage). Move finger DOWN — feel the soft depression between thyroid and cricoid cartilage. This is the cricothyroid membrane. It is your target. It is about 1 inch below the Adam's apple.
METHOD 1 — NEEDLE CRICOTHYROIDOTOMY (Faster, Buys Time)
- Position patient supine. Place roll under shoulders to hyperextend neck (unless C-spine suspected).
- Locate cricothyroid membrane — firm landmark palpation, then prep with Betadine/alcohol.
- Attach a 14-gauge IV catheter to a 10cc syringe. Nick skin with #11 blade if available.
- Insert needle at 90° to skin, applying suction on syringe. When air freely enters syringe — you are in the trachea. STOP advancing needle.
- Angle needle toward feet at 45°. Hold needle steady; advance catheter off needle all the way to the hub. Remove needle.
- Confirm placement: attach syringe, inject air — should flow freely. If resistance: reposition.
- Secure catheter with suture or tape. Connect to oxygen at 15 L/min or provide manual ventilations via syringe (plunger removed, attached to catheter).
- This provides approximately 30–45 minutes of oxygenation. Proceed to surgical cric as soon as able.
METHOD 2 — SURGICAL CRICOTHYROIDOTOMY (Definitive)
- Locate and prep membrane as above. Sterile gloves if available.
- Stabilize larynx with non-dominant hand — pinch between thumb and middle finger. Do NOT let it slip.
- Make a 1-inch horizontal skin incision over the membrane with #10 or #11 scalpel. Cut ONLY through skin — not membrane yet.
- Relocate membrane by touch. Make a second 1-inch horizontal incision THROUGH the cricothyroid membrane. A rush of air confirms entry. Do NOT cut vertically — avoid cricothyroid arteries.
- Insert hemostat into incision and dilate opening by spreading. Or hook index finger into incision to maintain opening.
- Insert ET tube (size 6–7) or smallest available airway tube through the opening, directed toward feet. Inflate cuff.
- Confirm placement: bilateral breath sounds, chest rise. Secure tube with tape or suture. Connect BVM.
- Ventilate at 12–16 breaths/min for adult. Monitor SpO2 if oximeter available. Reassess every 5 minutes.
No ET tube available: a ballpoint pen casing, IV tubing, or any non-collapsible hollow tube can maintain a surgical airway temporarily.
▶ PAIN CONTROL — FIELD ANALGESIC LADDER▼
Uncontrolled pain worsens shock, impairs cooperation, and reduces survival. Treat pain aggressively but safely. Assess pain on a 0–10 scale before and after treatment. Reassess every 30 minutes.
NEVER give opioids to: unconscious patients, respiratory rate <12, SBP <90 mmHg, suspected head injury, bowel obstruction. Never give aspirin or ibuprofen in active hemorrhage or shock.
STEP 1 — MILD PAIN (1–4): NON-OPIOID FIRST LINE
- Acetaminophen: 650–1000mg orally q6h. Maximum 4g/day. Preferred for head injury. No anti-inflammatory effect.
- Ibuprofen: 400–800mg orally q6–8h with food. Maximum 3200mg/day. Anti-inflammatory. Do NOT use with active bleeding, shock, kidney injury.
- Aspirin: 325–650mg orally q4–6h. Avoid with bleeding — inhibits platelet function for 7–10 days.
- Non-medication: splint fractures, elevate injured extremity, ice (first 48h), positioning of comfort, reassurance.
STEP 2 — MODERATE PAIN (5–7): ADD KETOROLAC
- Ketorolac (Toradol): 15–30mg IM or IV q6h. Maximum 5 days continuous use. Powerful NSAID — better than morphine for kidney stone, fracture, dental pain. Do NOT use with active bleeding.
- Combine with acetaminophen for additive effect — different mechanisms, no interaction.
STEP 3 — SEVERE PAIN (8–10): OPIOID (IF TRAINED AND AUTHORIZED)
- Morphine: 2–4mg IV/IM slowly q4h. Start low; titrate to effect. Monitor respirations — if <12/min, hold next dose.
- Oral Morphine (if no IV): 5–10mg orally q4h. Slower onset (30–60 min) but effective for field use.
- Have reversal agent: Naloxone (Narcan) 0.4–2mg IV/IM — reverses opioid overdose within 2 minutes. Essential if morphine is in your cache.
- Document dose, time, route, and patient response. Monitor every 15 minutes after opioid administration.
NON-DRUG ADJUNCTS
Wound immobilization reduces pain significantly — properly splinted fractures require less medication. Psychological support: calm voice, explain what you are doing, patient advocacy. Cold therapy: ice wrapped in cloth, 20 min on/20 off, first 48 hours only.
▶ INFECTED WOUND MANAGEMENT▼
In a grid-down scenario, wound infections are common and life-threatening. The sooner infection is recognized and treated, the better the outcome. A wound that was clean yesterday can be life-threatening tomorrow.
INFECTION PROGRESSION — RECOGNIZE THE STAGES
Stage 1 — Local inflammation (Days 1–3, Normal): Mild redness, warmth, swelling at wound edges. Small amount of clear/pale yellow fluid. This is normal healing — do NOT over-treat.
Stage 2 — Local infection (Days 2–5): Increasing redness spreading beyond wound edges. Warmth. Swelling. Pus — thick, yellow-green. Foul odor. Patient may have low-grade fever. BEGIN ANTIBIOTICS NOW.
Stage 3 — Spreading infection / Cellulitis: Red streaking spreading UP the limb from the wound (following lymph channels). Firm, hot, red skin. Fever >101°F. Patient feels ill, fatigued. URGENT — spreading sepsis. Escalate antibiotics, consider evacuation.
Stage 4 — Sepsis / Systemic: High fever OR hypothermia. Rapid heart rate (>100). Rapid breathing (>20). Confusion. Patient very ill. LIFE-THREATENING. Maximum antibiotics, urgent evacuation, IV fluids.
Stage 2 — Local infection (Days 2–5): Increasing redness spreading beyond wound edges. Warmth. Swelling. Pus — thick, yellow-green. Foul odor. Patient may have low-grade fever. BEGIN ANTIBIOTICS NOW.
Stage 3 — Spreading infection / Cellulitis: Red streaking spreading UP the limb from the wound (following lymph channels). Firm, hot, red skin. Fever >101°F. Patient feels ill, fatigued. URGENT — spreading sepsis. Escalate antibiotics, consider evacuation.
Stage 4 — Sepsis / Systemic: High fever OR hypothermia. Rapid heart rate (>100). Rapid breathing (>20). Confusion. Patient very ill. LIFE-THREATENING. Maximum antibiotics, urgent evacuation, IV fluids.
TREATMENT PROTOCOL — INFECTED WOUND
- Drain it: Infected closed wounds MUST be opened. If there is an abscess (fluctuant, pus-filled swelling): incise with scalpel at the most dependent point. Drain pus completely. Do not stitch it shut.
- Irrigate aggressively: High-pressure irrigation with 60mL syringe. Use sterile water or Dakin's solution (mild concentration: 3 tsp bleach per 4 cups boiled water + ½ tsp baking soda). Minimum 500mL per wound.
- Pack the wound open: Use wet gauze (moistened with sterile water or Dakin's). Pack loosely into wound cavity. Cover with dry outer dressing. Do NOT stitch infected wound closed.
- Change dressings twice daily: Remove packing, re-irrigate, re-pack. Each change: assess for improvement or worsening. Wet-to-dry packing debrides the wound with each change.
- Antibiotics: Skin/soft tissue: Amoxicillin 500mg TID x10 days. Deep wound/spreading: Amoxicillin 875mg BID or add Metronidazole 500mg TID (covers anaerobes in deep/contaminated wounds). Red streaking: Doxycycline 100mg BID.
- Elevate: Keep infected limb elevated above heart level. Reduces swelling and promotes drainage.
- Mark the margin: Use a permanent marker to draw a line at the edge of redness. Check every 4 hours — if redness expanding beyond the line, infection is spreading, escalate treatment.
- Track temperature: Check every 4–6 hours. Rising fever = worsening. Falling after antibiotics = improving.
NECROTIZING FASCIITIS (Flesh-Eating Infection): Severe pain out of proportion to appearance. Skin may look normal but tissue is dying underneath. Spreading rapidly — hours, not days. Gray/brown skin discoloration. Crepitus (crackling under skin = gas-producing bacteria). THIS IS A SURGICAL EMERGENCY. Antibiotics alone will not save the patient. Evacuate immediately.
▶ GI ILLNESS, DIARRHEA & DEHYDRATION▼
In every prolonged grid-down event in history, diarrheal disease has killed more people than trauma. Contaminated water plus close quarters equals outbreak. This protocol — hydration, hygiene, isolation — is the highest-yield medicine in this module.
DEHYDRATION ASSESSMENT
Mild (3–5% loss): Thirst, slightly dry mouth, normal vitals. Treat: ORS 50 mL/kg over 4 hrs plus replacing ongoing losses.
Moderate (6–9%): Very dry mouth, sunken eyes, reduced/dark urine, skin tent >2 sec, rapid pulse, listless. Treat: ORS 100 mL/kg over 4 hrs, small frequent sips, reassess hourly.
Severe (>10%): Lethargic or unconscious, no urine, weak/absent radial pulse, cold mottled extremities. This is hypovolemic shock — treat per the shock protocol, IV/IO fluids if trained and available; if not, drip ORS continuously by spoon/syringe if any swallow reflex, and evacuate if at all possible.
Infants: Add sunken fontanelle, no tears when crying, fewer wet diapers. Children dehydrate far faster than adults — do not wait.
Moderate (6–9%): Very dry mouth, sunken eyes, reduced/dark urine, skin tent >2 sec, rapid pulse, listless. Treat: ORS 100 mL/kg over 4 hrs, small frequent sips, reassess hourly.
Severe (>10%): Lethargic or unconscious, no urine, weak/absent radial pulse, cold mottled extremities. This is hypovolemic shock — treat per the shock protocol, IV/IO fluids if trained and available; if not, drip ORS continuously by spoon/syringe if any swallow reflex, and evacuate if at all possible.
Infants: Add sunken fontanelle, no tears when crying, fewer wet diapers. Children dehydrate far faster than adults — do not wait.
TREATMENT PROTOCOL
- ORS is the treatment. Recipe: 1 L clean water + ½ tsp salt + 6 tsp sugar. Vomiting patient: 1 tsp every 1–2 minutes still delivers a liter over hours — persist.
- Keep feeding. Continue breastfeeding infants. Adults/children: bland food as tolerated (rice, bananas, broth) — starvation slows gut recovery.
- Do NOT give anti-diarrheals (loperamide/Imodium) if fever or bloody stool — trapping an invasive infection makes it worse. OK for simple watery diarrhea in adults to enable travel/work.
- Antibiotics ONLY for: bloody diarrhea (dysentery), high fever with severe symptoms, or symptoms >7 days. First choice Ciprofloxacin 500mg BID x3 days or Azithromycin 500mg daily x3 days (children/pregnant: azithromycin). Most diarrhea is viral — antibiotics do nothing and burn irreplaceable stock.
- Track intake, output, and vitals on the flowsheet for moderate/severe cases. Urine returning to pale yellow = winning.
STOP THE OUTBREAK — HYGIENE & ISOLATION
- Isolate the patient's waste. Dedicated latrine/bucket, treated with lime or bleach, sited well away and downhill from any water source.
- Dedicated caregiver, dedicated dishes. Handwashing with soap after EVERY contact — this single step halts most outbreaks.
- Assume the water source is the culprit until proven otherwise. Boil (rolling boil 1 min) or treat ALL group drinking water immediately.
- Two or more cases from one water/food source = treat it as an outbreak: trace it, fix it, and inspect food handling.
RED FLAGS for higher care or maximum effort: severe dehydration, bloody stool with high fever, rigid/severely painful abdomen (possible surgical belly — appendicitis, obstruction), diarrhea in infants under 6 months, or any patient still deteriorating after 24 hrs of good ORS therapy.
▶ DENTAL EMERGENCIES▼
⚕ A dedicated dental module — IVORY — is part of the WATCHMAN Command Suite and covers the full scope of field dentistry: examination, diagnosis, local anesthesia, cement fillings, extractions, and long-term dental care planning. The protocols below cover immediate emergencies only.
In Vietnam, half of all sick call was dental. Dental pain incapacitates. In prolonged grid-down, dental emergencies are inevitable. These protocols do not require dental training.
TOOTHACHE — DIAGNOSIS
- Identify the bad tooth: touch each tooth in the area with something cold. The bad one will be very sensitive.
- Touch the same tooth with something warm. If it hurts with heat AND the pain continues 10 seconds after removing the heat source: the nerve is irreversibly damaged. This tooth requires extraction — it cannot be saved without a root canal.
- If sensitive to cold only (not heat): the tooth is likely saveable. Pain relief and antibiotics may buy time.
- Look for: visible cavity (dark hole), broken tooth, swelling at the gum line (abscess), pus.
TOOTHACHE — TREATMENT (Without Extraction)
- Pain: Ibuprofen 400–800mg q6–8h + Acetaminophen 500–1000mg q6h (can alternate for better control).
- Clove oil (Eugenol): Natural dental anesthetic — soak a small cotton ball and pack gently into the cavity. Provides significant temporary relief. Do not apply to gums — causes irritation.
- Temporary filling: Zinc oxide eugenol (IRM powder) mixed to putty consistency fills the cavity. Dental cement (Cavit or Dycal) also works. Keeps air and debris out of the nerve.
- Infection / Abscess: Amoxicillin 500mg TID x7 days. Metronidazole 500mg TID if no improvement in 48 hours. Penicillin-allergic: Clindamycin 300mg TID.
- Warm salt water rinses 4x daily — reduces inflammation and keeps area clean.
KNOCKED-OUT TOOTH (AVULSION) — TIME CRITICAL
Re-implantation success drops 1% per minute the tooth is out of the socket. Act immediately.
- Pick up tooth by the CROWN (white part) — do NOT touch the root.
- If dirty: rinse gently with clean water for 10 seconds. Do NOT scrub.
- Storage if not re-implanting immediately: place tooth in milk (best), or between the patient's cheek and gum, or in sterile saline. Do NOT use tap water — kills root cells.
- If tooth has been out <15 minutes: attempt re-implantation. Rinse socket gently. Insert tooth firmly with steady pressure in correct orientation. Have patient bite down on gauze.
- Splint to adjacent teeth: use dental wax, soft orthodontic wax, or carefully applied thin wire secured with dental cement or superglue. Patient on soft diet.
- Antibiotics: Amoxicillin 500mg TID x7 days. Pain: Ibuprofen + Acetaminophen.
- After 2 hours out: root cells are dead. Re-implantation still possible but pulp will decay. Treat it as a dental implant — it may scar into position.
DENTAL ABSCESS — FIELD DRAINAGE
A dental abscess that is not draining can spread to the jaw, neck, and airway. Airway compromise from dental infection is fatal. If swelling is closing the throat — evacuate immediately.
- Identify abscess: swelling at gum line near a tooth, fluctuant (soft and pus-filled when pressed), patient has severe pain, fever, swollen lymph nodes in neck.
- Begin Amoxicillin 500mg TID immediately. Add Metronidazole 500mg TID for more severe cases.
- If abscess is pointing (skin is thinned, feels like it wants to burst): drain it. Clean with Betadine. Small stab incision with #11 blade at the most fluctuant point. Allow pus to drain. Do not pack dental abscesses.
- Warm salt water rinses every 2 hours encourage continued drainage.
- Monitor for airway involvement: difficulty swallowing, difficulty opening mouth (trismus), swelling spreading toward the neck or under the chin. Any of these = evacuate urgently.
EVACUATION CRITERIA
Evacuate for dental emergency when: airway compromise, swelling spreading to neck or floor of mouth, jaw cannot open (trismus), not responding to antibiotics in 48 hours, or patient cannot maintain hydration due to pain.
▶ EMERGENCY CHILDBIRTH — FIELD DELIVERY▼
Birth is a natural process — in most deliveries your job is to catch, dry, and warm. The protocol exists for the minority that go wrong. If labor allows ANY chance of reaching skilled care, take it — especially for first babies, twins, preterm labor, or known complications.
IMMINENT DELIVERY — RECOGNITION
Delivery is imminent when: contractions 2–3 min apart, mother feels overwhelming urge to push or "have a bowel movement," or the head is visible at the opening (crowning). If crowning — you are delivering here. Do not attempt transport during crowning.
NORMAL DELIVERY
- Setup: cleanest available space, clean cloths/towels, gloves, two ties (boiled shoelace/umbilical tape) and clean sharp scissors or blade. Mother semi-sitting or side-lying — never flat on back.
- Let her push with contractions. Do NOT pull the baby. Support the head with gentle counter-pressure so it emerges slowly — this prevents tearing.
- As the head delivers, feel around the neck for the cord. If looped: slip it gently over the head. If too tight to slip, deliver through it (somersault the body out close to the mother) — clamp and cut only as a last resort.
- The head will rotate to one side on its own. Guide gently DOWN for the top shoulder, then UP for the bottom shoulder. The body follows fast and slippery — be ready.
- Note the time of birth. Immediately dry the baby vigorously with a clean cloth, then place skin-to-skin on the mother's chest and cover both. Drying + warmth + skin-to-skin IS newborn resuscitation for most babies.
- Baby not crying/breathing after 30 sec of vigorous drying and stimulation (rub the back, flick the soles): position the head neutral, clear the mouth then nose, and give gentle rescue breaths — puffs of cheek air, just enough to see the chest rise, 40–60/min.
- Cord: no rush. Wait at least 1–3 minutes (until it stops pulsing). Tie tightly at 4 finger-widths from the baby and again 2 finger-widths beyond, cut between with a clean blade. Leave the stump open to air — check daily for redness/odor.
- Placenta delivers on its own within 30–60 min. NEVER pull the cord — a torn cord or inverted uterus is a catastrophe. Keep the placenta: inspect that it looks complete (retained fragments cause hemorrhage and infection).
POSTPARTUM HEMORRHAGE — THE #1 KILLER OF MOTHERS
- Some bleeding is normal; soaking through pads continuously or steady free flow is not. Act at once.
- FUNDAL MASSAGE: cup the top of the uterus through the abdomen (at/below the navel) and massage FIRMLY in a circular motion until it contracts hard like a grapefruit. This is the primary treatment — it will hurt her, do it anyway.
- Put the baby to the breast immediately — nursing releases natural oxytocin and contracts the uterus.
- Empty her bladder (have her void) — a full bladder blocks uterine contraction.
- Bleeding continues: bimanual compression — one fist pressing into the abdomen against the uterus from above while the other hand supports below, compress and hold. Maintain for many minutes. Treat for shock, push ORS, evacuate if possible.
COMPLICATIONS — BRIEF DRILLS
Shoulder stuck after head delivers (dystocia): McRoberts — flex mother's knees hard against her chest while a helper presses firmly just above her pubic bone (NOT the top of the uterus). Retry gentle downward delivery.
Breech (butt/feet first): HANDS OFF until the body delivers to the shoulder blades on maternal effort alone, then support the body and keep it from dangling; if the head does not follow in ~3 min, place fingers to flex the baby's chin toward its chest and lift the body upward.
Cord comes out first (prolapse): Dire. Knees-to-chest position, push the presenting part OFF the cord with your hand and hold it there, keep the cord warm and moist, evacuate at any cost.
Breech (butt/feet first): HANDS OFF until the body delivers to the shoulder blades on maternal effort alone, then support the body and keep it from dangling; if the head does not follow in ~3 min, place fingers to flex the baby's chin toward its chest and lift the body upward.
Cord comes out first (prolapse): Dire. Knees-to-chest position, push the presenting part OFF the cord with your hand and hold it there, keep the cord warm and moist, evacuate at any cost.
AFTER: Watch mother for fever, foul-smelling discharge, or worsening bleeding for 10 days (childbed infection — treat aggressively with antibiotics per the selection guide). Newborn: warmth, feeding within the first hour, cord checks. Record delivery time, placenta status, and blood loss estimate in the mother's chart.
▶ EVACUATION CRITERIA — WHEN TO MOVE▼
In a grid-down scenario where resources are limited, the evacuation decision is one of the hardest and most important you will make. Evacuate too early and you expend resources and risk en route. Evacuate too late and the patient dies of something treatable. This guide establishes objective criteria.
EVACUATE IMMEDIATELY — MINUTES MATTER
▸ Uncontrolled hemorrhage despite tourniquet and wound packing
▸ Tension pneumothorax not fully relieved by needle decompression
▸ Airway obstruction not resolved by basic maneuvers or surgical airway
▸ Suspected internal abdominal bleeding (rigid abdomen, falling BP, mechanism of injury)
▸ Shock Class III–IV not responding to fluids
▸ Altered mental status after head injury (any deterioration from baseline)
▸ Anaphylaxis not responding to epinephrine
▸ Cardiac arrest with reversible cause (hypothermia, drowning, anaphylaxis)
▸ Burns >20% body surface area, or any burns to face/airway
▸ Dental/soft tissue infection spreading to neck or floor of mouth
▸ Tension pneumothorax not fully relieved by needle decompression
▸ Airway obstruction not resolved by basic maneuvers or surgical airway
▸ Suspected internal abdominal bleeding (rigid abdomen, falling BP, mechanism of injury)
▸ Shock Class III–IV not responding to fluids
▸ Altered mental status after head injury (any deterioration from baseline)
▸ Anaphylaxis not responding to epinephrine
▸ Cardiac arrest with reversible cause (hypothermia, drowning, anaphylaxis)
▸ Burns >20% body surface area, or any burns to face/airway
▸ Dental/soft tissue infection spreading to neck or floor of mouth
EVACUATE URGENTLY — HOURS MATTER
▸ Open fractures (bone through skin) — infection risk escalates hourly
▸ Compartment syndrome — fasciotomy window is 6 hours
▸ Eye injuries with vision loss
▸ Suspected spinal injury with neurological deficits
▸ Infection with red streaking (lymphangitis) or spreading cellulitis
▸ High fever (>103°F) not responding to antipyretics and antibiotics
▸ Diabetic crisis not responding to glucose management
▸ Seizures in a patient with no known seizure history
▸ Wound not improving after 48–72 hours of antibiotic therapy
▸ Inability to maintain oral hydration (vomiting everything)
▸ Compartment syndrome — fasciotomy window is 6 hours
▸ Eye injuries with vision loss
▸ Suspected spinal injury with neurological deficits
▸ Infection with red streaking (lymphangitis) or spreading cellulitis
▸ High fever (>103°F) not responding to antipyretics and antibiotics
▸ Diabetic crisis not responding to glucose management
▸ Seizures in a patient with no known seizure history
▸ Wound not improving after 48–72 hours of antibiotic therapy
▸ Inability to maintain oral hydration (vomiting everything)
TREAT IN PLACE — MONITOR CLOSELY
▸ Minor lacerations healing normally
▸ Closed fractures, properly splinted, CMS intact
▸ Mild-to-moderate infections responding to oral antibiotics within 48 hours
▸ First/second degree burns <10% body surface, not on face or hands
▸ Sprains and minor musculoskeletal injuries
▸ Mild dehydration responding to oral rehydration
▸ Stable chronic conditions (managed blood pressure, managed diabetes)
▸ Dental pain controlled with medication, no spreading infection
▸ Closed fractures, properly splinted, CMS intact
▸ Mild-to-moderate infections responding to oral antibiotics within 48 hours
▸ First/second degree burns <10% body surface, not on face or hands
▸ Sprains and minor musculoskeletal injuries
▸ Mild dehydration responding to oral rehydration
▸ Stable chronic conditions (managed blood pressure, managed diabetes)
▸ Dental pain controlled with medication, no spreading infection
TRANSPORT PRECAUTIONS
- Stabilize BEFORE moving: hemorrhage controlled, airway secured, fractures splinted, patient packaged for transport.
- Spinal precautions: if spinal injury suspected, log-roll onto rigid surface. Maintain neutral alignment throughout transport.
- Position by injury: head injury = slight elevation (30°). Shock = flat, legs elevated. Chest injury = semi-reclined. Unconscious = recovery position. Spinal = supine, neutral.
- Assign a dedicated attendant for transport — monitoring vital signs, airway, and consciousness level every 5 minutes en route.
- Document: injury, treatments given, medications (name, dose, time, route), vital signs trend, current status. This travels with the patient.
☐ MEDICAL SUPPLY INVENTORY
| TIER | ITEM | CATEGORY | ON HAND | NEEDED | STATUS | EXPIRY | LOCATION / CACHE | ACTIONS |
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📋 PATIENT CHARTS — ENCRYPTED 🔒 LOCKED
◈ START TRIAGE BOARD
Simple Triage And Rapid Treatment — Assess RPM: 30 (respirations) — 2 (CRT seconds) — Can Do (follows commands). 30 sec per patient. Triage only — do NOT treat unless stopping massive bleeding, opening airway, or treating shock.
🔴 IMMEDIATE (RED)
0
NEEDS IMMEDIATE CARE / WILL NOT SURVIVE IF UNTREATED
🟡 DELAYED (YELLOW)
0
NEEDS CARE WITHIN 2–4 HRS / STABLE FOR NOW
🟢 MINIMAL (GREEN)
0
WALKING WOUNDED / MINOR INJURIES ONLY
⬛ EXPECTANT (BLACK)
0
DECEASED OR UNSURVIVABLE WITHOUT ADVANCED CARE
🏥 MEDICAL ASSETS
⚕ WHAT IS THIS?
Medical infrastructure pushed from the Area Intel Map. Hospitals, urgent care, EMS stations, pharmacies, and fire / first-responder nodes within evacuation distance of your AO. Pre-event: evacuation planning, treatment-tier reference, regional capability awareness. Post-event: track facility degradation, plan alternates, identify which assets remain operational. Per Alton (Survival Medicine Handbook): the absence of advanced prehospital care converts otherwise-survivable trauma into mortalities at ~3x baseline rate. Knowing what existed and what remains is mission-critical.
Medical infrastructure pushed from the Area Intel Map. Hospitals, urgent care, EMS stations, pharmacies, and fire / first-responder nodes within evacuation distance of your AO. Pre-event: evacuation planning, treatment-tier reference, regional capability awareness. Post-event: track facility degradation, plan alternates, identify which assets remain operational. Per Alton (Survival Medicine Handbook): the absence of advanced prehospital care converts otherwise-survivable trauma into mortalities at ~3x baseline rate. Knowing what existed and what remains is mission-critical.
No medical assets logged yet. Push hospitals, urgent care, EMS, pharmacies, or fire stations from the Area Intel Map to populate this list.
📖 QUICK REFERENCE
⊕ VITAL SIGNS — NORMAL RANGES
| AGE GROUP | PULSE (BPM) | RESP RATE (/MIN) | BP SYSTOLIC | TEMP (°F) | O₂ SAT |
|---|---|---|---|---|---|
| Adult (18+) | 60–100 | 12–20 | 90–140 | 97–99 | >95% |
| Child (6–12) | 70–120 | 18–25 | 80–120 | 97–99 | >95% |
| Child (1–5) | 80–130 | 22–30 | 75–115 | 97–99 | >95% |
| Infant (<1 yr) | 100–160 | 30–40 | 70–100 | 97–99 | >95% |
Tachycardia (>100 bpm) = pain, fever, shock, dehydration, anxiety. Bradycardia (<60) = severe hypothermia, head injury, medications, athletes (normal). RR >30 or <8 = emergency. Any temp >103°F or <95°F = urgent action.
⊕ RULE OF NINES — BURN SURFACE AREA ESTIMATION
ADULT
Head & Neck9%
Each Arm (entire)9%
Chest (front)9%
Abdomen (front)9%
Upper Back9%
Lower Back9%
Each Thigh9%
Each Lower Leg9%
Perineum1%
CHILD (MODIFIED)
Head & Neck18%
Each Arm9%
Chest (front)9%
Abdomen (front)9%
Back (entire)18%
Each Leg (entire)13.5%
Perineum1%
Burns >20% body surface = HIGH shock risk. Burns to face/hands/feet/genitals always require aggressive treatment. 2nd/3rd degree burns over 10%+ in field = urgent.
PALM METHOD: Patient's own palm (fingers together) = approximately 1% body surface area. Useful for irregular burn patterns.
⊕ HEMORRHAGIC SHOCK — CLASS STAGING
CLASS I — Compensated (<750 mL / <15%)
Pulse <100, BP normal, RR normal, mental status normal. Skin normal. Minimal symptoms.
Pulse <100, BP normal, RR normal, mental status normal. Skin normal. Minimal symptoms.
CLASS II — Mild (750–1500 mL / 15–30%)
Pulse 100–120, BP normal or slightly low, RR 20–30, anxious/agitated. Skin pale, cool, clammy.
Pulse 100–120, BP normal or slightly low, RR 20–30, anxious/agitated. Skin pale, cool, clammy.
CLASS III — Moderate (1500–2000 mL / 30–40%)
Pulse >120, BP dropping (systolic 70–90), RR 30–40, confused. Skin pale/mottled, CRT >2 sec.
Pulse >120, BP dropping (systolic 70–90), RR 30–40, confused. Skin pale/mottled, CRT >2 sec.
CLASS IV — Severe (>2000 mL / >40%)
Pulse >140 (or absent), BP systolic <70, RR >35 or agonal, lethargy/unresponsive. Death imminent without immediate intervention.
Pulse >140 (or absent), BP systolic <70, RR >35 or agonal, lethargy/unresponsive. Death imminent without immediate intervention.
⊕ MEDICATION REFERENCE — FIELD USE
| MEDICATION | USE | ADULT DOSE | NOTES / CAUTIONS |
|---|---|---|---|
| Ibuprofen (Advil/Motrin) |
Pain, inflammation, fever | 200–800mg q6–8h (max 3200mg/day) | Do NOT use for head injuries, GI bleeding, shock, or kidney disease. Take with food. |
| Acetaminophen (Tylenol) |
Pain, fever | 325–1000mg q4–6h (max 4000mg/day; 3g if elderly) | Preferred for head injuries. Do NOT exceed dose — liver damage. Avoid with alcohol. |
| Aspirin | Cardiac event, anti-platelet, pain | 325mg chewable (cardiac); 81mg daily (prevention) | Do NOT give to children (<16) — Reye's syndrome risk. Avoid if bleeding, head injury. |
| Diphenhydramine (Benadryl) |
Allergic reactions, anaphylaxis support, sleep aid | 25–50mg q4–6h (max 300mg/day) | ADJUNCT to Epinephrine for anaphylaxis — never sole treatment. Causes drowsiness. |
| Epinephrine 1:1000 (EpiPen) |
Anaphylaxis, cardiac arrest | 0.3mg IM outer mid-thigh. Repeat in 5–15 min if needed. | Children <66 lbs: 0.15mg (EpiPen Jr). Refrigerate; expires ~1–2 years. Auto-injector preferred. |
| Amoxicillin (Fish-Mox Forte) |
Wound infection, cellulitis, dental | 500mg 3x/day (TID) for 7–10 days | Penicillin family. Avoid if PCN allergic. Good for skin/soft tissue infections. |
| Doxycycline (Bird-Biotic) |
Infections (Lyme, respiratory, wound) | 100mg 2x/day (BID) for 7–14 days | Do NOT give to children <8 or pregnant women. Take with full glass water. Sun sensitivity. |
| Ciprofloxacin | Gram-negative infections, UTI, some wound infections | 500mg 2x/day (BID) for 7–14 days | Avoid in children and pregnancy. Reserve for resistant infections. |
| QuikClot / Celox | Hemostatic agent — hemorrhage control | Pack directly into wound, apply firm pressure 3–5 min | Celox: chitosan (shrimp-based) — caution if severe shellfish allergy. QuikClot: kaolin-based. |
| Oral Rehydration (ORS) |
Dehydration, shock support, diarrhea | Drink to thirst; 200–400mL/hr if dehydrated | Make: 1L water + ½ tsp salt + 6 tsp sugar. Electrolytes critical for recovery. |
⊕ PEDIATRIC CONSIDERATIONS
Airway: Smaller, softer, more anterior. Even slight obstruction is dangerous. Use smaller OPA/NPA. Sniffing position to open airway (not full head tilt).
CPR: 2-finger compressions (infant), one-hand for small child. Rate 100–120/min. Depth 1.5" (infant) to 2" (child). AED: use pediatric pads for <55 lbs.
Hypothermia: Children lose heat much faster — smaller mass relative to surface area. Dry immediately, wrap with adult bodies if needed.
Burns: Use modified Rule of Nines. Children are more susceptible to dehydration and burn shock. Aggressive oral hydration.
Dehydration signs: Sunken fontanelle (infant), dry mouth, no tears, no urine for >8 hours, sunken eyes.
Medications: Ibuprofen 5–10mg/kg q6–8h. Acetaminophen 10–15mg/kg q4–6h. No aspirin under 16. Diphenhydramine 1mg/kg up to 25mg.
CPR: 2-finger compressions (infant), one-hand for small child. Rate 100–120/min. Depth 1.5" (infant) to 2" (child). AED: use pediatric pads for <55 lbs.
Hypothermia: Children lose heat much faster — smaller mass relative to surface area. Dry immediately, wrap with adult bodies if needed.
Burns: Use modified Rule of Nines. Children are more susceptible to dehydration and burn shock. Aggressive oral hydration.
Dehydration signs: Sunken fontanelle (infant), dry mouth, no tears, no urine for >8 hours, sunken eyes.
Medications: Ibuprofen 5–10mg/kg q6–8h. Acetaminophen 10–15mg/kg q4–6h. No aspirin under 16. Diphenhydramine 1mg/kg up to 25mg.
⊕ START TRIAGE — RPM QUICK REFERENCE
| STEP | ASSESS | RESULT | TAG |
|---|---|---|---|
| 1. RESP | Is patient breathing? | Not breathing after airway repositioned | BLACK |
| Starts breathing after airway opened | RED | ||
| Respirations >30/min | RED | ||
| 2. PERF | Radial pulse + CRT? | No radial pulse OR CRT >2 sec | RED |
| Pulse present AND CRT ≤2 sec | → Check Mental Status | ||
| 3. MENTAL | Follows simple commands? | Unresponsive or disoriented | RED |
| Can follow commands but cannot get up | YELLOW | ||
| Follows commands AND can walk | GREEN |
When in doubt between categories — always tag the HIGHER priority. In START, only three interventions are permitted: stop massive bleeding, open airway, elevate legs for shock.
⊕ 9-LINE MEDEVAC REQUEST — RADIO FORMAT
For HAM/radio-equipped MAGs. Transmit in order. "BREAK" between categories on Line 3 and 5 if mixed. Encrypt grid on Line 1 per unit SOP.
| LINE | ITEM | BREVITY CODES / FORMAT |
|---|---|---|
| 1 | Location of pickup site | Grid coordinates (encrypt if COMSEC active) |
| 2 | Radio frequency & callsign | Pickup site radio freq + callsign (can send in clear) |
| 3 | Patients by precedence | A=Urgent (2hr) • B=Urgent-Surgical • C=Priority (4hr) • D=Routine (24hr) • E=Convenience |
| 4 | Special equipment | A=None • B=Hoist • C=Extraction equipment • D=Ventilator |
| 5 | Patients by type | L=Litter (non-ambulatory) • A=Ambulatory (walking) |
| 6 | Security of pickup site | N=No enemy • P=Possible enemy • E=Enemy present • X=Armed escort required |
| 7 | Method of marking LZ | A=Panels • B=Pyrotechnic signal • C=Smoke (state color) • D=None • E=Other |
| 8 | Patient nationality/status | A=US Military • B=US Civilian • C=Non-US Military • D=Non-US Civilian • E=POW/EPW |
| 9 | NBC contamination | N=Nuclear • B=Biological • C=Chemical • None=Routine (omit if not contaminated) |
Example call: "ALPHA BASE, this is SUTTON ONE requesting 9-Line MEDEVAC. Line 1: [grid]. Line 2: [freq] SUTTON ONE. Line 3: Alpha, one urgent. Line 4: Alpha. Line 5: Litter, one. Line 6: November. Line 7: Charlie, purple smoke. Line 8: Alpha. Line 9: None. OVER."
⊕ GLASGOW COMA SCALE (GCS)
| RESPONSE | DESCRIPTION | SCORE |
|---|---|---|
| EYE OPENING (E) | ||
| Spontaneous | Opens without stimulation | 4 |
| To voice | Opens to verbal command | 3 |
| To pain | Opens to painful stimulus | 2 |
| None | No response | 1 |
| VERBAL (V) | ||
| Oriented | Knows person, place, date | 5 |
| Confused | Converses but disoriented | 4 |
| Inappropriate | Random words, no conversation | 3 |
| Incomprehensible | Moaning, groaning only | 2 |
| None | No verbal response | 1 |
| MOTOR (M) | ||
| Obeys commands | Follows verbal instructions | 6 |
| Localizes pain | Moves toward painful stimulus | 5 |
| Withdraws | Pulls away from pain | 4 |
| Flexion | Abnormal flexion (decorticate) | 3 |
| Extension | Abnormal extension (decerebrate) | 2 |
| None | No motor response | 1 |
INTERPRETATION (E+V+M = TOTAL)
15 — Normal, fully conscious
13–15 — Mild TBI / Concussion
9–12 — Moderate TBI
3–8 — Severe TBI / Deep coma
3 — Deepest coma (minimum possible)
Any downward trend in GCS = URGENT. A drop of 2+ points from baseline = immediate escalation. Reassess every 15 min for head injury patients.
AVPU quick field check: Alert (GCS ~15) • Voice (GCS ~12) • Pain (GCS ~8) • Unresponsive (GCS 3–5)
⊕ ANTIBIOTIC SELECTION GUIDE — GRID DOWN
Use the narrowest effective antibiotic. Overuse breeds resistance. Always complete the full course. Discontinue only if confirmed allergy or clear adverse reaction.
| INFECTION TYPE | FIRST CHOICE | SECOND CHOICE | IF PCN ALLERGIC | DURATION |
|---|---|---|---|---|
| Skin / Soft Tissue (wound, cellulitis) | Amoxicillin 500mg TID | Doxycycline 100mg BID | Clindamycin 300mg TID | 7–10 days |
| Spreading / Red Streak (lymphangitis) | Amoxicillin 875mg BID | Doxycycline 100mg BID | Clindamycin 300mg TID | 10–14 days |
| Dental / Oral Abscess | Amoxicillin 500mg TID + Metronidazole 500mg TID | Amoxicillin 500mg TID alone | Clindamycin 300mg TID | 7 days |
| Respiratory (mild) (bronchitis, sinusitis) | Azithromycin 500mg Day 1, 250mg Days 2–5 | Doxycycline 100mg BID | Azithromycin (already OK) | 5–7 days |
| Respiratory (severe) (pneumonia) | Doxycycline 100mg BID + Azithromycin | Ciprofloxacin 500mg BID | Ciprofloxacin 500mg BID | 10–14 days |
| Urinary Tract (UTI) | Ciprofloxacin 500mg BID | Doxycycline 100mg BID | Ciprofloxacin (OK) | 7 days (3d uncomplicated) |
| Deep / Anaerobic (abdominal, bite wound) | Amoxicillin 500mg TID + Metronidazole 500mg TID | Ciprofloxacin 500mg BID + Metronidazole | Clindamycin 300mg TID + Metronidazole | 10–14 days |
| Lyme Disease | Doxycycline 100mg BID | Amoxicillin 500mg TID | Azithromycin 500mg QD | 21 days (full course critical) |
| Animal / Human Bite | Amoxicillin 875mg BID | Doxycycline 100mg BID | Clindamycin 300mg TID + Ciprofloxacin 500mg BID | 10–14 days |
Metronidazole: do NOT consume alcohol during treatment — severe reaction. Doxycycline: avoid in pregnancy and children <8. Sun sensitivity — cover up. Ciprofloxacin: avoid in children, pregnancy; reserve for resistant cases.
★ TRAINING LOG — GROUP MEDICAL CERTIFICATIONS
Key certifications for grid-down preparedness: Stop the Bleed, TCCC (Tactical Combat Casualty Care), Wilderness First Aid, CPR/AED, WEMT, Combat Lifesaver, CERT (Community Emergency Response Team), PHTLS.
| MEMBER | CERTIFICATION / COURSE | LEVEL | DATE COMPLETED | EXPIRY DATE | CERT STATUS | ISSUING ORGANIZATION | ACTIONS |
|---|
No training records. Log group medical certifications to track readiness.
⚗ TOOLS — FIELD CALCULATORS
▶ PEDIATRIC DOSE CALCULATOR▼
For use when standard medical care is unavailable. Always verify weight before dosing. When in doubt, use the lower dose range. Never dose by age alone — use weight.
lbs
kg
Enter patient weight and select medication to calculate dose.
▶ PREGNANCY DATING — EDD CALCULATOR▼
Enter the first day of the last menstrual period (LMP). Due date is LMP + 280 days (Naegele's rule). Accurate to about ±2 weeks with regular cycles; without ultrasound this is the best available dating. Pair with the Emergency Childbirth protocol.
Prenatal routine when no higher care exists: visit monthly to 28 weeks, biweekly to 36, weekly to delivery. Each visit: weight (flowsheet), BP (pre-eclampsia watch — flag BP ≥140/90 with headache/vision changes/swelling), fundal height, fetal movement after ~20 weeks. Chart the mother like any other patient — the pregnancy is a problem-list entry.
◈ GROUP MEDICAL READINESS
Loading readiness data...
■ GENERATE DOCUMENTS
Build print-ready documents from your MEDICAL COMMAND data. The full binder collects every reference and status sheet into one continuous print job for a 3-ring binder. Patient records are handled separately — they print one at a time from an unlocked chart, so private records stay out of the bulk binder.
BINDER BUILD
⎙ Print Full Binder
One continuous print job containing every reference and status sheet, each section starting on a fresh page behind a cover sheet: Protocols, Quick Reference, Supply Inventory, Training Log, Readiness Report, and Medical Assets. Designed to be three-hole punched and dropped into a binder. Patient records are intentionally excluded — print those individually from Patient Charts.
OUTPUT 1
Trauma Protocols
All grid-down field-medicine protocols, fully expanded. Post at the aid station or keep in the medic bag.
OUTPUT 2
Quick Reference Cards
Condensed field cards — dosing, vitals, triage and decision aids for fast bedside lookup.
OUTPUT 3
Supply Inventory
Your full 3-tier inventory with on-hand vs. needed counts and locations. For audits and resupply runs.
OUTPUT 4
Training Log
Group medical certifications with completion and expiry dates. For readiness reviews and gap planning.
OUTPUT 5
Readiness Report
Current group medical readiness score with training, supply, and casualty breakdown and key gaps.
OUTPUT 6
Medical Assets
Hospitals, urgent care, EMS, pharmacies and responder nodes pushed from the Area Intel Map.
PATIENT RECORDS
Patient charts are private clinical records and are never part of the binder build. Open the Patient Charts tab, unlock, open a chart, then click ⎙ PRINT CHART — or use the per-row ⎙ PRINT — to print exactly one chart at a time.
Data Management
Storage key: ao_overwatch_trauma_one_v1 · Export before clearing. Import replaces all current MEDICAL COMMAND data.
? USER MANUAL
WATCHMAN:MEDICAL COMMAND
FIELD MEDICINE // GRID DOWN READY · MODULE 09
User Manual
Read this before you need it.
MEDICAL COMMAND is your group's field-medicine command sheet for situations where professional medical care is delayed or unavailable. It holds your treatment protocols, your medical inventory, your patient records, a mass-casualty triage board, your team's training, and a readiness score that ties it all together. Everything runs offline and stores only on this device.
Read firstThis module does not replace training or a clinician. The protocols are written for austere, grid-down conditions only. Whenever modern medical care is reachable, use it. Reading is not a substitute for hands-on courses like Stop the Bleed, TCCC, or Wilderness First Aid.
CONTENTS
What's in here
TAB 01
Protocols
Step-by-step trauma and field-medicine procedures for grid-down care — bleeding control, airway, CPR, burns, fractures, hypothermia, shock, anaphylaxis, head and chest injuries, wound infection staging, dental emergencies, and evacuation criteria.
- Click any protocol header to expand or collapse it.
- Use ⎙ PRINT ALL PROTOCOLS to print every protocol, fully expanded, on its own pages.
NotePrinting always expands collapsed protocols first, so nothing is left out of the printout.
TAB 02
Supplies
Your medical inventory, organized in three tiers: Tier 1 (IFAK / personal carry), Tier 2 (medic bag), and Tier 3 (community clinic cache). The module ships pre-loaded with a complete recommended list; set your own on-hand counts.
- Filter by tier with the tier buttons, or search by name.
- Add, edit, or delete items. On hand vs. needed drives the low-stock flags and the readiness score.
- Record an expiry date to catch items before they lapse.
- ⎙ PRINT LIST prints the inventory for audits or resupply runs.
TAB 03
Patient Charts (Encrypted)
Each patient is a persistent chart with a longitudinal history, not a single note. All patient data is encrypted at rest (AES-GCM 256) and can only be read after the records are unlocked.
First-time setup (the boss)
- Open Patient Charts. On a new install you set the suite-wide Master password — the boss’s skeleton key that opens every encrypted module.
- A one-time recovery key is shown once. Use 🔶 PRINT KEY CARD to print it, or write it down, and store it offline. It is the only way back in if the passwords are lost, and it is never shown again.
- You are then offered the optional JWBuild rescue choice. NO (the default) means only you can ever unlock the records. YES saves a locked rescue file on this computer only — it cannot open anything by itself, but if you ever lose both passwords and the key card, you can send it to JWBuild, verify you are the license owner, and receive a one-time unlock code. Either way, nothing is ever transmitted. Change your choice later with the 🛡 RESCUE button in the header while the records are open.
Adding the daily operator password
The everyday Primary password (for the medic) is set after setup, not during it.
- While the records are open, click 🔑 OPERATOR PW (or the amber banner) to set it. The boss can do this at handover, or the operator can do it on a session opened with the Master or recovery key.
- From then on the medic unlocks with their own Primary password and never needs the Master. The Master still works and can reset a forgotten Primary.
Unlocking and locking
- Enter the Master or the operator password to open the records. USE RECOVERY KEY covers a forgotten password.
- 🔒 LOCK closes the records for the session — nothing is readable again until unlocked.
If every password and the key card are lost
If rescue was enabled at setup, the lock screen shows 🛡 JWBUILD RESCUE (last resort). Download the rescue file, email it to JWBuild support with your WATCHMAN license key, and after identity verification you receive a one-time unlock code. Entering it opens the records once and immediately forces a new Master password and a new recovery key card — the emailed code can never open anything again, and the operator password must be set again afterward. If rescue was declined and both passwords and the key card are gone, the records are unrecoverable by design.
Inside a chart
- The top of the chart is the spine: demographics, blood type, weight (for dosing), code status, and the PAMI safety band — Problems, Allergies, Medications, Immunizations.
- + NEW ENCOUNTER opens a guided note that walks OLD CARTS / PQRST, vitals, exam, assessment, plan, and return precautions, so a complete note comes out even under pressure. Each patient builds a stack of dated encounters over time. Click an encounter to expand the full note; use EDIT to correct one.
- + VITALS on the Vitals Flowsheet records a timestamped set of vitals with no note required. On critical patients take vitals every 15–30 minutes — the trend (rising pulse with falling BP) catches decompensating shock before it is obvious. For routine clinic visits, record a weight each time: unexplained weight loss over weeks is the early flag for chronic infection and malnutrition, and serial weights are the growth record for children.
- ✓ GIVE next to an active medication records a dose on the MAR (Medication Administration Record) — what was actually given, when, and by whom. The med list shows last-given and estimated next-due times, so nothing is double-dosed or missed across shift changes.
- On the Triage Board, → CHART promotes a casualty into a full patient chart — the triage tag data becomes encounter #1. Category changes are logged on the tag as retriage history.
- The Body Map uses the DD Form 1380 (TCCC card) anatomical figures. Tap the figure to drop a numbered marker (wound, burn, tourniquet, fracture); tap a marker to edit, resolve, or delete it. The anterior view is mirrored — sides are always the patient’s left and right, and the region is captured automatically. TQ markers require a time. Markers print with the chart. Set a follow-up date on an encounter and the patient list flags DUE (amber, within 3 days) and OVERDUE (red) — the clinic recall list. The immunization panel automatically flags a tetanus booster due at 10 years (or 5 for dirty wounds). Baseline findings — scars/prior surgery, implants and devices, amputations/prosthetics, identifying marks — use hollow square markers in muted colors so permanent features never read as fresh injuries. These matter in an emergency: a pacemaker changes AED pad placement, hardware changes splinting, dentures are an airway item, and scars and marks identify a patient who cannot speak.
- Adding a medication that matches a recorded allergy triggers a drug-allergy alert you must confirm before overriding.
- Hover or tap any abbreviated label (RR, SpO2, GCS, route, criticality, and so on) for a plain-language tip.
Charts print one at a timePatient charts are never part of the bulk binder. Open a chart and click ⎙ PRINT CHART, or use the per-row ⎙ PRINT, to print one full chart on its own sheet. Private clinical records stay out of your reference binder.
Existing records migrate automaticallyAny patient records from the earlier version fold into the encrypted vault the first time it is set up — each old note becomes that patient’s first encounter — and the plaintext copies are removed.
TAB 04
Triage Board
A START (Simple Triage And Rapid Treatment) board for mass-casualty sorting into four categories: Immediate (red), Delayed (yellow), Minimal (green), and Expectant (black).
- + ADD CASUALTY logs a casualty with RPM findings and an initial category.
- Drag casualty cards between columns to reassign as conditions change.
- ⎙ PRINT BOARD prints the current board state.
Triage vs. patient recordsTriage casualties are a fast incident snapshot, separate from full patient charts. Casualties are not part of the patient binder rules.
TAB 05
Medical Assets
Hospitals, urgent care, EMS stations, pharmacies, and fire / first-responder nodes pushed in from the Area Intel Map. Pre-event it supports evacuation planning and regional capability awareness; post-event you track which facilities remain operational.
TAB 06
Reference
Condensed quick-reference cards for fast bedside lookup. Use ⎙ PRINT REFERENCE CARDS to print them for the medic bag or aid station.
TAB 07
Training Log
Track each group member's medical certifications — course, level, issuing organization, completion date, and expiry. Status colors flag current, expiring, and expired certs. This feeds the training half of your readiness score.
Key certs to track: Stop the Bleed, TCCC, Wilderness First Aid, CPR/AED, WEMT, Combat Lifesaver, CERT, PHTLS.
TAB 08
Tools
Field calculators. The Pediatric Dose Calculator converts weight (lbs/kg) and a selected medication into a weight-based dose with the right liquid volume or tablet count, plus safety warnings.
Dose safelyAlways dose by weight, never by age alone. When in doubt, use the lower end of the range, and verify weight before dosing.
TAB 09
Readiness
A single group medical readiness score, 0–100, combining training readiness and supply readiness, minus a penalty for active critical/guarded casualties. It surfaces your key gaps — zero-stock items, expired certs, expiring supplies — so you know what to fix first. Press ↻ REFRESH SCORE after making changes.
OUTPUTS
Generate Documents
The Generate Docs tab is the print hub. Each section can be printed on its own, and the feature button builds the whole binder at once.
- Print Full Binder — one print job: a cover sheet, then Protocols, Reference, Supplies, Training Log, Readiness, and Medical Assets, each starting on a new page.
- Individual outputs — print any one section by itself.
- Data management — export, import, and clear your data (see below).
PRINTING
Printing & the binder
Every print uses your browser's print dialog, so you can send it to a printer or "Save as PDF."
What goes in the binderThe full binder includes Protocols, Reference, Supplies, Training Log, Readiness, and Medical Assets. It deliberately leaves out the patient charts, the triage board, the calculators, and this manual — those are either live tools or private records. Print the manual on its own with the ⎙ PRINT MANUAL button at the top of this page.
Patient privacy by designPatient charts can only be printed one at a time, from inside an unlocked chart. They are never swept into the binder.
YOUR DATA
Saving & moving data
Module data (supplies, triage, training, medical assets) lives in this browser on this device under the key ao_overwatch_trauma_one_v1. Patient charts live separately, encrypted, under ao_overwatch_trauma_one_charts_v1. Nothing is sent anywhere.
- Export (JSON) saves a backup file — keep one off-device. For privacy, exports do not include patient charts; that PHI stays in the encrypted vault only.
- Import (JSON) restores a backup or moves your data to another device. Import replaces current module data and does not touch the encrypted patient vault.
- Clear All Data wipes supplies, triage, and training on this device. Export first. The encrypted patient charts are separate — lock or move them with the vault.
ThemeDark is the default tactical display. Settings → Display → Light switches the whole suite to a field-manual aesthetic. Your choice is shared across all WATCHMAN modules.
REFERENCE
Glossary
| SOAP | Subjective, Objective, Assessment, Plan — the standard structure of a clinical note. |
| PAMI | Problems, Allergies, Medications, Immunizations — the chart’s at-a-glance safety summary. |
| OLD CARTS | Onset, Location, Duration, Character, Aggravating, Alleviating, Radiation, Timing, Severity — the guided history prompts in an encounter. |
| Encounter | One dated visit/note inside a patient’s chart; a chart holds many over time. |
| Master / Primary | Master is the boss’s suite-wide password; Primary is this module’s daily operator password. Either opens the records. |
| Recovery key | One-time key shown at setup; the last way in if both passwords are lost. |
| START | Simple Triage And Rapid Treatment — the mass-casualty sorting method used by the Triage Board. |
| RPM | Respirations, Perfusion, Mental status — the three START checks. |
| IFAK | Individual First Aid Kit — the personal-carry (Tier 1) supply level. |
| TCCC | Tactical Combat Casualty Care — a field trauma training standard. |
| CMS | Circulation, Motor, Sensation — the distal check after splinting an injury. |
| Tier 1/2/3 | Supply levels: personal IFAK, medic bag, community clinic cache. |
TRAINING
Demo sandbox
MEDICAL COMMAND ships with a demo sandbox — a separate copy pre-loaded with a worked example: stocked supplies with expiry warnings, three full patient charts with SOAP notes, flowsheets, and body maps, a triage board covering all four categories, and a training log with current, expiring, and expired certifications.
Opening and leaving. In the live module, click DEMO in the sidebar under this manual. Inside the demo, that same slot reads RETURN TO LIVE and takes you back. The amber DEMO / SANDBOX badge in the top bar tells you which copy you are in.
Your real data is safe. The demo keeps everything in separate storage slots, including its own encrypted charts vault and its own rescue file. Nothing you do in the demo — adding patients, setting passwords, enabling rescue, clearing data — can touch your real records.
Practice the encryption ceremony. The demo is the safe place to walk through the full Patient Charts setup: master password, the recovery key card, and the optional JWBuild rescue choice. Do it once in the demo before doing it for real. A rescue file downloaded from the demo is named with DEMO so it can never be mistaken for a real rescue request.
Resetting. The ⟲ RESET DEMO button in the top bar wipes all demo data — including any password you set in the demo — and restores the clean sample sandbox.
MEDICAL COMMAND USER MANUAL · © 2026 WATCHMAN Suite, LLC · FIELD MEDICINE MODULE