Fog of War: How Would You Respond to an IED Detonation? - ITS Tactical

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Fog of War: How Would You Respond to an IED Detonation?

By Scott Breuker

In light of recent events, I’d like to go over my suggestions for the medical response to an improvised explosive device explosion. As we’ve seen during the past ten years of fighting overseas and recently here in Boston, IED’s are the bad guy’s weapon of choice.

Let’s not forget that this isn’t the first attempt to detonate a bomb in CONUS, but hopefully it will be the last. First of all, I just want to take my hat off to the response to the  attack on Boston. It truly was a best outcome of a horrible terrorist attack on our county. But why did it go in our favor?

The nature of a 26 mile race makes it a softer target. How can you secure that much real-estate in a major city? Anyone who has competed in a marathon knows the number of EMS personal that are used. Having worked major sporting events as a police officer, I know that they pull in every available body they can. You had EMS, local RN’s and doctors all there and ready to help. So what can everyone else do if they are in that situation?

The Response

The first thing that needs to be mentioned is to know the enemy’s TTP (Tactics, Techniques and Procedures.) That being said, they often set up secondary devices with the hope of taking out first responders. Take that second to look around the scene, not only for other threats, but to determine ground zero of the incident. Time, distance and shielding goes into play as well. We need to look for the victims that are in the worst shape, not necessarily the ones yelling the loudest.

What should you expect to see if you respond to an IED? Let’s use the injuries from the Boston marathon. Partial or complete amputations, patients near the blast suffered burns which causes a compromised airway, penetrating trauma to the chest wall and lungs. It doesn’t matter if it’s an explosion or gun shot wound, we’ll have the same response. That response that we’ll go over today is MARCH, specifically focusing on the first three issues to address.

M – Massive Bleeding
A – Airway
R – Respiration
C – Circulation
H – Head injury/Hypothermia.

Control Bleeding

TourniquetThe textbook answer to control bleeding is to activate 911 first and transport to higher medical care. In the real world, massive bleeding needs to be controlled immediately. The ideal way to do this is with a tourniquet.

A pre-manufactured tourniquet is THE BEST TOOL. When it come to massive bleeding from an extremity, you can’t go wrong with a tourniquet. We have massive amounts of data in tourniquet use over the past ten years and it all says the same thing, TOURNIQUETS SAVE LIVES.

Tourniquet placement is crucial, go as high on the limb as you can. It doesn’t matter if its a gun shoot wound or an IED. Bullets and shrapnel can travel and tear flesh up above the apparent wounds.

Remember that arteries are elastic in nature and when severed, they travel up into the muscle. I think this was best shown in Black Hawk Down. Tighten the tourniquet until you see the bright red blood stop. This will be extremely painful and be aware that the patient may try to loosen it to relieve the pain.

If you don’t have a tourniquet it’s OK. A field expedient tourniquet can be made from a piece of cloth that’s two inches wide and a stick to act as a windlass to tighten it. Army cravats are small and work awesome in a pinch.


First thing is to talk to the patient. If they answer, they have a good airway (for now.) If they have a compromised airway, you’ll have to try and open it. Head tilt, chin lift or the jaw thrust. We are also observing the patient as they move to a position of comfort, especially with head trauma. If they need to sit a certain way to breathe, let them.

If you have a Nasopharyngeal Airway and you feel they would tolerate it, then use it. Look for soot around their mouth and nose indicating a compromised airway. These patients can go downhill quickly if unnoticed. They will experience swelling of the vocal cords and eventually will lose the ability to breath on their own. They need ALS (advanced life support) now.


The third thing moving down our MARCH list is Respiration. This area is the neck down to the belly button on all sides. With blast injuries, we’re concerned about penetrating trauma to the lungs and the thoracic cavity. You’ll need to do a thorough assessment if you’re looking for very small shrapnel wounds. More than likely you’ll see no blood coming from these wounds, so use your hands and stretch the skin to expose hard to spot wounds.

If you do find any wounds, you’ll need to place an airtight seal over it to prevent air from entering the chest cavity. Ideally this is a pre-manufactured chest seal like the HALO, but plastic bags will work also. When using plastic, remember to tape off all edges and listen for air entering and escaping from the chest cavity.


Photo credit Dan Lampariello

Photo credit Dan Lampariello

The above picture is to get you thinking. How would you handle a situation like Boston, who would you help first? Events like this will never be a cut and dry exercise. If this would have been your town, how long would it be until help arrived?  Is help coming? EMS protocol is to ensure the scene is safe, before doing anything. Remember that.

Take your fully stocked med bag or kit out of the equation for a moment and think outside the box, “what can I use to treat the injured if I didn’t have my kit?” In care under fire, we only do the M and A (controlling massive bleeding and opening the airway). That will buy you time, so do you go from one patient to another controlling bleeding and managing the airway? I’d say yes. We need to be the most help to the most people. I don’t want one alive patient that is all neat and bandaged up, when I could have performed the important steps for more people.

Fog of War

How would you handle a bystander that wants to help, but may know nothing about a medical first response? While he doesn’t have a clue what to do, give him a specific job as this will allow you to do your assessment.

It’s easy to look at what happened in any situation and say I’d do this, or they didn’t do this. We live in a dangerous world, it could be a bomb in Boston or a shooter in a movie theater. Most people reading this article will have a plan when they sit down in a restaurant. Such as facing the door know and what their best exit is, but that’s where it stops. When the bullets stop flying and the debris settles, that’s when you will understand the fog of war.

Editor-in-Chief’s Note:  Remember, use your best judgement when it comes to responding to a situation. Be an asset and not a liability, get proper training and be prepared. This article should be used to get you thinking, not as a replacement for proper training.

Scott Breuker has been a Federal Agent with the National Nuclear Security Administration for the past six years. He is currently on the Weapon Recovery Team and carries a secondary duty as Team Medic. Prior to that, he served 8 years active duty in the U.S. Army as a Military Policeman. Between the Army and State Department contracting, he has 4 years experience of high threat dignitary protection in 28 countries.  

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    Great article. Thank you.

  • Navy Doc

    For everyday carry of a tourniquet I suggest the NATO tourniquet as it is much smaller than the SOF or CAT, which are to big to carry if you’re not kitted up. The disadvantages to the NATO is that it is near impossible to put on your own arm and it isn’t as intuitive. However, it’s like a pistol: The one you have on you works better than the one you don’t carry because it’s too much of a pain in the ass. The SWAT tourniquet (the rubber one) is even smaller, but it is completely worthless because it gets too slick to grip when your hands are bloody.

    • Scott Breuker

      Very valid points doc. I can’t stand the SWAT tourniquet. I’ve been around it some and I have a hard time believing that it is an effective tool.

    • ChrisB

      With the SWAT, I think your best bet is to try to tie a knot, put a stick or something under that knot, and use it to twist.

      I’ll have to look into the NATO version; never heard of that before.

    • JB Gleason

      I am going to politely disagree with both of your perceptions of the SWAT-T tourniquet. You opine that “it is completely worthless because it gets too slick to grip when your hands are bloody.” I have used this tourniquet in multiple LTT iterations and didn’t have this problem at all. Prior to the LTT, when the tourniquet first came on the market, we slicked a student up with motor oil and it worked fine there too. Your comment smacks of “someone I know who knows a guy who told him he heard that…” If this is DIRECT PERSONAL EXPERIENCE OR OBSERVATION then say so. But don’t bash a tool otherwise. The big caveat here is that the SWAT-T is in no way shape or form anywhere as good (IMO) as the CAT or SOF-T(W). The ability to self apply just isn’t there. But I carry the SWAT-T in my med bag for use on others and can also say (based on direct personal experience) that it makes a great pressure dressing, chest wrap and I even fashioned a sling from one for a separated shoulder. Given the cheap cost and the focus of this article, it would be an ideal MASCAL tool for a medic to carry as back up to his primary TK’s. By the way, there are several legit non-manufacturer medical studies showing that the SWAT-T is quite effective at occluding arterial and venous flow at LOWER pressure levels than other commercial TK’s. Apparently based on its greater width thus meaning the patients are in less pain when it is applied. As far as the NATO TK, I couldn’t disagree more about that device. I have one and have tried to use it. I think it is pretty worthless but seeing as that I haven’t used it in a real-world situation, I keep that to myself.

  • Ken


    While I can appreciate your background, I disagree with your acronym as the order of treatment in a mass casualty situation. You NEVER treat massive bleeding first. It’s ALWAYS “A,B,C” (Airway, Breathing, Circulation).

    Great, you spend 4 minutes working on getting the bleeding stopped with your tourniquet, not noticing that the patient has been without OXYGEN for 5 minutes ( the minute it took you to get there plus the 4 minutes it took to stop the bleeding) due to a compromised airway. Saved a limb; allowed irreparable brain damage, or worse, death. Could be the bleeding stopped because the heart stopped for a lack of oxygen!!!

    Our brains automatically see massive amounts of blood and gravitate toward stopping the leak. As first responders, we have to TEACH ourselves to check the AIRWAY and BREATHING FIRST!!!

    Take the case of a gunshot wound to the chest affecting the lungs. If you don’t “plug the hole” immediately, you are going to have a “sucking chest wound” creating a tension pneumothorax. If you wait until you stop the bleeding before you address that, they won’t be able to take a breath.

    ALWAYS, ALWAYS, ALWAYS, check the AIRWAY & BREATHING FIRST!!! Then plug the leaks!!!!


    • Scott Breuker


      That is the school of thought and the go to for EMS. I am writing this from the combat realm and this is the standard training for troops OCUNOS. Times change and so do SOP’s. This is my direction from my medical control and I have a very progressive Doctor and med control. Tourniquets were a No Go ten years ago in civilian EMS now you find them on more and more ambulances.

      I am focused on getting people to think about ways to solve the problems. Lets look at the difference between the EMS I was taught and the combat role I fill. Combat medics and potential first responders are at the scene. We focus on stopping the bleeding because blood is the one thing that keeps you alive. Look at the new hands only CPR, NO more respiration’s. If you witness a cardiac arrest you start the AED before CPR. The focus is getting blood flowing. The average person that may respond will have an NPA at the most. We don’t teach blind sweeps anymore, and they do not have suction, BVM or high flow O2. So the focus shifts to controlling the bleeding. The same thing can be said for bleeding as lack of O2, you spend five mins getting an airway they bleed out from there legs. Focus on Massive bleeding part of the story. I am not saying put band aids, I am talking tourniquets. If it takes me longer then 60 seconds to put a tourniquet on my doc would take my med bag.

      As far as the GSW to the Chest. Those are not massive bleeders. I do live tissue every year and we F up the pigs. Tensions is a later sign then bleeding and airway.

      I believe that the you need to look at time lines. What I am discussing is an immediate response, most EMS are not on the scene that quick so massive bleeding took care of its self.

      I am trying to help and I am going off of the Doctors, Corpsman, and 18 Deltas that are in charge of our program. My way is a way and given the Mortality curve from the past 12 years this is the preferred way to treat.


    • Ken


      I get what you’re saying. Here is where my concern lies. You and I are trained to understand what “massive bleeding” really is. The average guy reading this post may not be.

      You know how a tablespoon of blood can create a huge mess. To the untrained person, seeing that will trigger the “massive” perception and because they have incorporated the “Delta” treatment acronym , they will treat the wrong thing first, rather than do a quick appropriate assessment. I think I would have been a bit more comfortable, if you had spent a little more time clarifying the definition of “massive bleeding” and the scenarios you’re referring to so as to assure that your readers don’t do the wrong thing first. I think this dialogue has been helpful in doing just that.

      As to the airway issue, I’m not talking about inserting an airway. I’m just talking about the simple things like head positioning. If the patient has been blown across the street and is laying up against a wall with his head bent over such that his airway is occluded and the artery in his right arm is severed, simply move him enough to where you can get his head tilted back to give his airway a chance and then stop the leak.

      I understand that combat medicine has advanced and am thankful for that. Most of the EMS procedures in use today are the results of the advances learned in combat medicine. I just think that is important to remember when you are writing a blog like this, who your audience is. Yes, there are a lot of former military/law enforcement/ems that read this. If your post was only going to be read by that group, I wouldn’t have said anything. They’ve been trained with the other background information necessary to able to make good decisions.

      But there are readers here who have no background or training whatsoever. Because of that, I think there has to be much more information to assure that those people don’t do the wrong thing. There are no guarantees but at least it gives them some odds.

      I think the additional explanations that you have provided in the “Responses” has added significantly to the original post.

      Thanks for taking the time to dialogue and for sharing. Thank you for your service to our country,


    • Lee

      I have to agree with Ken on this one. I am just a fourth year medical student, however I have had the benefit of spending my training at a level one trauma center, volunteering at a marathon and completing the Basic and Advanced Disaster Life Support courses.

      While combat medicine definitely guides civilian emergency medicine (e.g. tourniquets), ignoring the airway while trying to place a tourniquet doesn’t make any sense. And CPR is still performed with respirations by healthcare providers; while circulation is definitely more important the blood is still going to eventually lose all of its available oxygen if it is not replaced. Chest only CPR is most effective when there are relatively short response and transport times, otherwise the patient is going to need oxygen from somewhere. Furthermore the AHA also realized that many laypeople weren’t performing CPR because they were afraid of mouth to mouth.

      If one looks at the SALT triage algorithm taught as part of BDLS and ADLS (courses designed to train first responders to these types of events), repositioning the airway, needle decompression and controlling massive hemorrhage are both included under the Assessment stage as life saving interventions. Thus, one doesn’t even place them in a triage category until all relevant lifesaving measures are performed, and the patient is reassessed for spontaneous respirations. I guess then in the field one would hope that tourniquet placement and airway repositioning would be done nearly simultaneously (especially if responding as a team), but if I had to choose, I would first complete my assessment, then take the 20sec to reposition the airway rather than stopping to take the minute placing a tourniquet when I have no idea how long the patient’s brain has not received any oxygen. I think this becomes even truer with laypeople; they probably aren’t going to know how to place a tourniquet, the best I would expect is the placement of direct pressure. However, anyone who has ever taken a CPR class knows how to reposition an airway.

      Like I said before, the SALT triage paradigm was designed with an immediate response to a large casualty incident in mind. In the case of the Boston bombing, first responders were there in seconds, as they would probably be in most large scale events. Regarding the tension pneumo issue, I agree that it would become life threatening later than the massive bleeder or airway obstruction, but ONLY IF you witnessed the event. Otherwise, as Ken said, the patient could be suffocating while you are placing your tourniquet (the issue is the compression of the lung, not the blood loss itself), and it takes less than 10sec to listen to the lungs and place a decompression needle.

    • Scott Breuker

      Tactical Combat Casualty Care Guidelines – 8 August 2011

      * All changes to the guidelines made since those published in the 2010 Seventh Edition of the PHTLS Manual are shown in bold text. The most recent changes are shown in red text.

      Basic Management Plan for Care Under Fire

      Return fire and take cover.
      Direct or expect casualty to remain engaged as a combatant if appropriate.
      Direct casualty to move to cover and apply self-aid if able.
      Try to keep the casualty from sustaining additional wounds.
      Casualties should be extricated from burning vehicles or buildings and moved to places of relative safety. Do what is necessary to stop the burning process.
      Stop life-threatening external hemorrhage if tactically feasible:
      – Direct casualty to control hemorrhage by self-aid if able.
      – Use a CoTCCC-recommended tourniquet for hemorrhage that is anatomically amenable to tourniquet application.
      – Apply the tourniquet proximal to the bleeding site, over the uniform, tighten, and move the casualty to cover.

      This is the first part of the TCCC guidelines. This is what I am taught and is taught to troops. Standing next to a guy and having him blow up is very different then showing up to a house where a guy fell off of a ladder.

      Nothing that you guys are saying is wrong. It is the standard for trained personal. I am wanting to get people thinking and looking for additional training. Of the 100K likes on Facebook I bet 90% have little training and the only time they would perform this is if they are very near the attack site.

      Most readers of this do not carry a 14 gauge needle(or 2) nor do they even know what a Bilateral Needle Decompression is or does. The steps I went over are saving lives everyday in this type of situation and is being taught to 1000’s of troops every year.


    • Sean

      I have to agree with Scott. Back in march I went through a TCCC Certification course, and we were taught the acronym SCABC to prioritize casualty care:

      Self Aid/ Situational Awareness
      Circulatory – major bleeding
      Circulatory- minor bleeding

      You can go for 3 minutes without air, you will die much faster if you are bleeding out of your femoral at full tilt. Also, I personally wouldn’t want to carry a tq that I can’t self apply, just in case I have to conduct self aid. Just my thoughts on the subject. Great article.

  • Raven

    Excellent article. Your plan DOES need to include everything from start to finish. Not just the gunfight or initial blast but the post shitstorm cleanup as well.

  • Good article.

    Any chance we can get a follow-up from ITS concerning triage strategy following an IED, or other in-threat situation where safety isn’t certain (forest fire, tornado, etc)?

  • In the Corps we drilled over and over again:

    Stop the Bleeding
    Start the Breathing
    Treat the Wound
    Treat for Shock

    Great article, I like the MARCH acronym.

  • John

    After a 20+ year professional career in the fire/EMS service, I would like to add that there is a significant risk of further long term injury to trauma patients by improperly placed/used tourniquets.

    It is very important to get real training from a qualified instructor in the use and application of any type of tourniquet. A youtoube video is not real training. You need hands on practical training with a qualified instructor.

    Because anyone can purchase an SOF, CAT, or NATO tourniquet, it does not mean they know how to apply it and when to use it. Even with my extensive career experience in EMS, I have had zero training in the use of these medical devices so I have chosen to not carry one in my gear until I find a qualified instructor to train me in it’s use. My personal decision is based on responsible medical care.

    I know that these devices can be a truly life saving tool but proper training is just as important as the tool itself.

  • Ken

    One other question that is slightly off topic.

    In the above scenarios, how much time does your training teach you that you have (in the worst-case scenario) before a victim will bleed out? Say a severed femoral artery.

    I’m genuinely looking for some good working data.

    Thanks again, and have really found the dialogue helpful.


    • John

      I’m no expert in blast injuries but my experience in EMS would lead me to the conclusion that a transected aorta from the pressure wave of a well built high explosive IED is a greater life threatening injury. I have seen several transected aortas from blunt force trauma and these patients were way dead long before EMS arrival.

      I have responded on a few traumatic leg amputations and have seen some severed femoral arteries. As long as the artery is cut clean and mostly straight across, the artery will clamp down on itself and although the injury is visually overwhelming, there is really not as much blood loss as you would expect.

      Crushing, tearing injuries are another issue. Which is what you will probably find with blast/frag injuries. When large arteries like the femoral are ripped and have have elongated/angled ripping and shearing, the muscles in the artery wall cannot contract and limit blood loss.

      One of the worst injuries of this type I have seen is a leg severed in a large agricultural auger. The twisting and crushing injuries caused the bleeding to be much more severe than I had seen before. Because the leg had been ripped off about 4 inches from the pelvis, there was really no way to apply any type of a tourniquet. We used femoral pressure point at the pelvis/groin. That worked somewhat. What really matters in injuries like this is rapid fluid replacement via IV in order to prevent the cardiovascular system from shutting down because there is no blood to pump. IV fluid replacement with bleeding control is what saves lives in these scenarios. Sadly the patient in this event died several days later from massive infection due to his injuries.

      So to answer your question, there is no definitive bleed out time for a severed femoral artery. Certain medications like blood thinners will greatly accelerate blood loss and the mechanism of injury will dictate how well the body can compensate. Other factors that can affect blood loss are environmental conditions, patient physical fitness, other traumatic injuries associated with the event, and since every human body is different, there is no way to say how much time you have.

      In the IED scenario presented in the article above, blast injuries are dictated by the types of explosives used. High explosives generate the types of blast wave that cause tearing/shearing of internal organs and vessels. These injuries will kill you much faster than having a limb torn off.

      Lower order explosives similar to the devices used in the Boston Marathon bombings generate injuries from the frag that is created from the pressure cookers that were used. Different mechanisms of injury from similar devices will create differing injury types.

      Hopefully someone with military field medicine experience will add some actual field experience in regard to blast injuries to this conversation. I have never responded to blast injuries but I have had training in how to deal with them. Training is not the same thing as real world experience.


    • Ken


      Thanks for the feedback. My question was not necessarily in regards to this conversation, but one I was having offline with a buddy. Simply trying to find some “guidelines” from people with more expertise than myself.

      Thanks again to all for the great dialogue.

    • Scott Breuker


      I will try and get you the case studies and intern the timelines it creates. I have been out of the office for the past few weeks.

    • Ken


  • Nick Grant

    Excellent article

  • Ray

    Just a few thoughts and my opinions. Take what you like, trash what you don’t.

    I’ve been taught by a few Tier 1 medics to place the TQ as high on the limb as you can. (Lost a foot…TQ the upper thigh) The reasoning is that the path of the wounding object may cause internal injuries significantly further from the entry point and those arteries like to retract like window shades. It made sense but I had been taught that the TQ would be the spot where they person lost their limb. Repeated TCCC studies have shown this is FALSE. Most limbs were not lost after the application of the TQ.

    Also, we switched from black to orange TQs. During training scenarios at the (civilian) hospitals the medical personnel repeatedly cut off the black ones thinking that it was gear. To help alleviate the bright orange target, the TQs are wrapped in black plastic that falls off when you rip it from your gear. (we carry one TQ attached to a vest and one in the IFAK)

    CAT TQs bend on large thighs and the Velcro gets attached to other gear. But is seems to be the easiest for first time learns. Designate a training one as the windless bends if you practice hardcore.

    I use the SWAT-T in my civilian car medic kits. Multi function and cheaper. I keep a SOFT-T with them. SOFT-T on all kits and for patrol.

  • G

    A lot of talk about airway vs bleeding in a mass casualty situation. If you have that many casualties, it is likely that you will not be able to help all of them. Do the most good for the most you can help, right? If I am a casualty in a mass casualty circumstance, and I am not breathing, then I am more than likely beyond help anyway. Go on and do the most good for someone more salvageable than I am……  Just 2 cents from an old cold warrior (remember the cold war wasn’t always cold).
    G  RN, MSN, FNP-BC , former combat nurse, former first responder, former EMT

  • Ian McDevitt

    Whoever commented on the MARCH pneumomic, it’s from the Brits. The SAS and SBS have been using it for years. Not a bad article. Some inaccurate info though… the dude who wants to focus on airway first. The article was geared to a Tactical Medical bent so BLEEDING first… the dude who wrote it, it was ALSO focused on blast injuries (multi-system trauma) which actually brings priorities full circle back to airway bleeding circulation so your kind of both right….to the guy who mentioned the “blast wave” I think your refering to detonation speed which has to do with the forward edge of the wave with high explosive (above 21,000fps) and the term is “brissance”. it also has to do with a deflagration as opposed to a detonation which is beyond the scope of what you wrote…..otherwise, not bad. Not entirely acccurate, but not bad. I do like your little MOLLE trauma kits though. Never see any of them when I operate though. Too poor and way, way to much action.

  • NathanRelph

    The title of the article is How Would You Respond to an IED detonation. So this would be a possible care under fire situation if you follow the Tactical Combat Casuality Care guidelines. So our care for our patient is only return fire and apply a tourniquet. In a civillian setting and there was an IED blast hemmorage would still be my first priority. If you get hung up on airway your patient will bleed out and all your work on that airway is for not.

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