NFL Helmets and little kids.

If you put a standard NFL football helmet on an 80 pound kid who can run 40 yards in 8 seconds, he is unlikely to be protected by his helmet pad.  The current NFL helmet systems are all designed (poorly) for a large adult moving at a 4.4 sec 40 yard dash.   The big guy gets his concussions at 10 to 15 ft/sec squared.  The little guy can't generate that speed or acceleration so he is more likely to have collisions in the 8-10 ft/sec squared range.  Most NFL pads are so stiff that they only start to absorb energy at peak accelerations of 15 ft/sec squared.   Putting NFL helmets on little kids is akin to strapping bricks on their heads.

Lawrence Livermore National Laboratory Helmet Pad Report

The lawrence livermore national Lab compared the army ACH pads to the NFL pads.  When adjustments were made to the size and shape of the pad to even out the playing field, the ACH pads performed better in all tests when compared to the football helmet pads.   I will figure out how to link to the report so you can read it for yourself.

See the Medical Security International website Helmet page to see the full report.

Twinsburgbulletin.com - How to save a life

Twinsburgbulletin.com - How to save a life

Helmet Propaganda - Helmet Design Suits Today’s Combat Conditions

Wanna see an example of helmet propaganda?

Helmet Design Suits Today’s Combat Conditions -http://www.designworldonline.com/articles/6596/250/Helmet-Design-Suits-Today-s-Combat-Conditions.aspx

There is so much wrong with this article it pains me. The Ops-Core bump helmet as described does not on its own meet any standards, ASTM or otherwise. This article fails to mention what if any padding is placed inside this helmet. If the manufacturers are wise, they will use the approved padding that is must be placed in the Advanced Combat Helmet.

The design of this helmet leaves critical areas of the head such as the temple, widely exposed. The bolts that hold on the chin strap penetrate through the backface of the helmet and extend as deep as the pads are thick, therefore allowing the bolts to directly contact the skull of the wearer even before the pads have begun to compress. The lightweight design does impress people, however, its true benefit in blast and bump is limited to those blasts and bumps that may accompany rain drops.

I would disregard this article as editorial fluff and ignorant ramblings.

Helmet pad performance

The big debate in helmets seems to be focused on the brand of the helmet.  This is really irrelevant since we don't know what goes into the specific brands.   We need to discuss helmet pad technology to really get at this issue properly.   Most helmets function as a system,  that means the parts all work together.  It makes little sense to talk about the shell since it doesn't do all the work of protecting the person.

First, lets look at what the shell does.  The shell is the hard covering of the helmet, it is its outer most limit.  The shell usually holds any accessories, colors, and masks.  It also contributes to the look and impression of the helmet.  In the case of a ballistic helmet, the shell prevents bullets and fragments from penetrating into the head.   In bump or sports helmets the shell acts to deflect the force of the blow and contain the pad system.

The army gives its soldiers the Advanced Combat Helmet.  The helmet shell is made of a kevlar based material that prevents shrapnel from going through into the person's head.  The army has done extensive testing and has chosen to use a material called Zorbium in pads to line the inside of the helmet.  The polymer pads absorb much of the energy of an impact and are the key to the helmet's ability to prevent brain injury from bumps and blunt trauma.   The manufacturer of the material also makes a liner that absorbs some of the energy from blast waves encountered by the wearer.

The pads perform the important role of absorbing the energy of an impact.  The function of the pads can be understood when we look at how the pads work.  Any pad inside a helmet will absorb energy.  The exact behavior of the pad depends on its materials.  Zorbium is a unique polymer and displays characteristics unique to itself and was specifically engineered for helmet padding.  Many other pad systems are made of foams and polymers that were transferred from other purposes.  In one older helmet pad system, the foam used in the pads came from carpet underlayment cushion.

The helmet pad absorbs energy by changing its shape under the stress of the impact. In order to better understand how pads work, its important to break this down further.   When something impacts the helmet, the force of the blow can be understood as an impulse.  This technical term expresses the amount of energy transferred over the time of transfer.  Most impulses from blunt impacts last less than 15 milliseconds.  The pad absorbs much of the energy through crushing.  The best pads crush evenly and allow the helmet/head to be decelerated evenly and smoothly.  Stiffer pads require more energy to crush while softer pads crush at lower energy levels.  Once a pad is fully crushed it reaches a point where it no longer absorbs energy and only transmits it.

The next feature of a good pad is that it does not rebound quickly.   The best pads will crush and not spring back quickly.  The recoil could actually transmit energy into the head.  We really want a pad that will crush and stay crushed until the energy is removed.  

The last feature is pad thickness.  A thin pad will only be able to absorb a small amount of energy compared to a thicker pad.  Since most helmets are a specific size relative to the sport or activity, the thickness of the pad is often limited by the size of the shell.  If you look at some of the newer NFL helmets, they are bigger, allowing for thicker pads.  

The New First Aid.

Hopefully you have seen the IFAK article printed by NPR on their website, if not, check out the links on my blog.  The article talks about the "silent chaos" present in the aftermath of the shooting in Tucson, which left 6 people dead and changed the lives of a congresswoman and many others.   The article mentions "rare little packs".  The author then tries to explain what an IFAK is.  My previous post describes a typical IFAK.  I also make mention of the origins of the IFAK and why it exists at all.  

In essence, the IFAK represents a shift in how we provide first aid during and after a shooting incident.  I like to call this shift the "New First Aid".   Why is it new?  The nature of the care is the same. The techniques are age old techniques but they are applied in a new way with new technology.    Lets look at the concept of the "New First Aid".

The New First Aid that I mention involves new technology and a new mindset.  First the technology.  About 10 years ago the U.S. military embarked on a campaign to save lives on the battlefield.  The movie BlackHawk Down, based on events in Mogadishu, Somalia in the late 90's documents the running gun battle that cost the lives of a number of soldiers who, despite using first aid, succumbed to their injuries before getting to a higher level of medical care.   The army looked closely at every casualty, surviving or deceased, and determined that they needed to improve the average soldier's ability to treat bleeding and prevent shock.   Out of that realization came a search for a better way to stop bleeding.

The first step was to add tourniquets to the list of items each soldier carries. The tourniquet can stop bleeding from wounds to the arms or legs.  Application of a tourniquet has saved hundreds of lives since its adoption by the U.S. military.   The second step was the addition of new clotting bandages.  The army invested heavily in chitosan based technology and developed a bandage that eventually became a gauze product.  When applied with direct pressure to a bleeding wound the chitosan gauze accelerates the clotting process and results in less blood loss than with "old fashioned" gauze.   Today they are several products on the market which are used to stop bleeding.  I have used hemcon products over 100 times and have seen impressive results.  There is research that suggests that the chitosan gauze is twice as effective as the non chitosan products.    I can assure you that there is new technology in development which will continue to improve the life saving ability of the average person.

The mindset which accompanies the "New First Aid" is that of survival during chaos.  Traditional first aid training always reinforces the concept of scene safety.  This is done to prevent unnecessary injury to the rescuer.  It makes perfect sense that a rescuer should wait until the scene is safe before becoming involved in providing medical care.  However, it is also recognized that some injuries like major bleeding can lead to death within minutes.  The field of tactical medicine developed precisely because a group of docs and medics decided to copy the military model of providing medical care before the scene was safe.  Today there are medics and docs on SWAT teams all across the country.   There are tactics and techniques which make it possible for an injured person to treat themselves to stop bleeding and their partner can assist if needed.  I propose taking that one step further. I believe the New First Aid should be made available to each and every willing person.

If you think I am a bit nuts, just think about Automated External Defibrillators or AED's.  The AED provides a rapid solution for sudden cardiac death.  The computers can now diagnose and treat a fatal heart rhythm with the press of a button.  Cardiac  life saving is now in the hands of the public and the solution is prepositioned where the people live and work.    Now consider the multitude of violent acts committed against people across the globe.  How many lives could be saved if this simple hemorrhage control technology was more widely available?   I don't have the answer but it seems intuitively simple to me.

With that I will go back to my job of making as many people as possible aware of the New First Aid and the life saving technology available to them.  

The IFAK Explained.

FAK = Individual First Aid Kit - 

The Individual First Aid kit (misnamed in the NPR article on silent chaos as "infantry first aid kit") is the mature form of the military first aid kit.  The contents of the IFAK are all included because of key discoveries in military medicine.  IFAK's come in several varieties but all contain similar products.  One key assumption behind the IFAK is "the threat is still active"  These kits came out of the world of military combat.  These kits were designed to be carried all the time, and used by an injured individual who could not reach the medic before they lost too much blood.  They were designed to be used by the individual who carries it, for themselves.  The treatments they contain are for emergency conditions that will kill a person within minutes.  They are not intended to be the only medical solution for everything. 

A typical IFAK can include at least one Tourniquet, one compressive dressing, one hemostatic bandage, one wound seal, one nasal airway and one pair of medical gloves.   Additional products are placed in the kit for a variety of different reasons. Let's look at each one briefly.

 The Tourniquet

The tourniquet goes way back, at least as far as Napolean's army.  Boy Scouts and most wilderness first aid training includes some discussion of tourniquets.  Mainstream first aid classes don't include tourniquets because its use had fallen out of favor in the last century.  However, in the last 20 years, military experience showed us the need to have a quickly applied, rugged, and simple device to stop bleeding from wounds to the arms and legs.  There are several current models to choose from.  Each has its own strengths.  The U.S. military forces equip their soldiers with either the Combat Application Tourniquet (CAT) or the Special Operations Forces Tactical Tourniquet (SOFT-T).  Other devices exist but are not easily applied with one hand only (assumes the other arm is the injured arm).    

Tourniquets can stop bleeding from arm or leg wounds when they are applied above the site of injury (between the heart and the injury).   They work by compressing the blood vessels in the limb.  They must be applied tight enough to stop arterial flow (tighter than the pressure in the vessel - systolic blood pressure).   If they are not tight enough, they can slightly increase blood loss by blocking only the draining veins and causing a back up of blood in the limb.  This also accounts for the concern civilian docs have about their use. After prolonged blockage of blood flow, the limb can sustain damage.  This is not usually a concern in the U.S. civilian EMS world as most seriously injured trauma patients can be transported to advanced care in less than 2 hours.  We promote the use of the SOFT-T because it is very simple and hasn't had the problem of cheap knock-offs that fail.  

Compressive Dressings 

Unlike tourniquets, which are not placed directly on the wound, Compressive Bandages are designed to be placed directly on the bleeding wound.  First aid training always emphasizes the need to apply direct pressure to any bleeding wound.  Direct pressure provides local compression of the arteries and veins feeding the wound. This allows the blood flow to slow and the normal clotting systems of the body to act and stop the bleeding.  Compressive bandages work well on moderate bleeding and allow the rescuer to apply the dressing and then move to another care task.  Modern compressive dressings are often strong enough to create a tourniquet effect so care needs to be used in applying them. They should not be left in place beyond the end of the emergency to avoid damage to the limb.   Most modern compressive bandages are long enough to be applied to the torso as well as arms and legs. Tourniquets are only used on arms and legs.   

Hemostatic Bandages

The word Hemostatic translates to "Blood Stop".  Hemostatic Bandages should be considered a major discovery linked to the high cost of the wars over the last 20 years.  These bandages, along with tourniquets have saved hundreds of lives in combat.  The current technology in hemostatic dressings come directly from the military's need to stop bleeding quickly and simply without surgery.  Most current hemostatic bandage technology is based on the concept that normal blood will clot when it comes into contact with a substance that is not normally in contact with blood.  That sounds funny but in the body, blood is always undergoing clotting (coagulation) and clot breakdown (fibrinolysis).  Anytime blood comes into contact with anything not normally present inside a blood vessel, it starts to clot (think heart attacks or stroke).   Some substances prevent clots but we will ignore this now.  All hemostatic bandages are based on a common concept, they are usually gauze products coated or made from a substance that accelerates the clotting process.  One popular product uses Kaolin, a component of clay or sand.  Others use forms of silica, cellulose, or chitosan. These compounds all interact with the clotting system to accelerate clotting.  In most cases these products accelerate clotting many times the normal rate.  This allows even severe bleeding to be controlled when direct pressure is applied along with the special hemostatic dressing.  I have my preference for chitosan products since it seems to work better than the others and also has antimicrobial effects.

Hemostatic dressings can stop severe bleeding from anywhere on the body.  Tourniquets and compressive dressings work best on limbs where they can be wrapped tightly.  Hemostatic bandages allow bleeding to be controlled even in areas that are difficult to compress such as the scalp, neck, chest, abdomen and groin.   In fact, military training often includes the use of tourniquets for arm and leg wounds and direct pressure with a hemostatic bandage to anywhere else.   Keep in mind that direct pressure on the neck can collapse the airway so care must be taken to allow the patient to breath.  Its always bad when the patient can't breath. That brings us to the next item....

Nasal Airway.

The nasal airway or "nasal trumpet" is designed to allow air to pass through the nose and past the tongue.  They are at best a temporary and minimalist solution for airway control.  My personal opinion is that Nasal airways are of limited use as most awake patients will naturally protect their own airway and find a body position that allows some breathing.  The use of a nasal airway requires specific training and is very uncomfortable to insert (both for the patient and the rescuer).  Before I use nasal airways, I always attempt to position the patient in the sniffing position or perform a chin lift to improve airflow.  If a nasal airway is necessary for survival in the minutes following a crisis, then the patient is usually a candidate for a more advanced airway device or procedure.  IF your kit has a nasal airway, be prepared to use it by seeking the proper training.  In some states you have to be a licensed medical provider to use one.  

Wound Seal

Wound seals or "chest seals" are basically occlusive dressings (impervious to air at least). Most commercial wound seals are medical grade sticky patches.  Imagine a plastic or rubberized film coated with stuff as sticky as those live catch sticky mouse or rat traps.  They are intended to seal up a wound to the chest.  Some "chest seals" actually have valves in them that supposedly make them safer to use on a sucking chest wound.  The valve is supposed to allow pressurized air from inside the chest to escape, preventing a "tension Pneumothorax- a deadly condition).  Examples of chest seals with valves include the Aschermann Chest Seal and the Bolin Chest Seal. Simpler wound seals don't have valves but also stick to the skin tightly and prevent air and fluid from moving past them.   

Here's the deal with penetrating chest wounds.  The hole on the outside is not nearly as much of a problem as the possibility of having additional holes on the inside of the chest.  Once the chest wall is open to the outside lung function is compromised.  If the lung is also damaged, then air can accumulate inside the chest and compress the lungs and big blood vessels, leading to a "tension pneumothorax" which can kill the person.  Tension pneumothorax leads to rapid deep breathing, shortness of breath and eventually death.  Treatment of a tension pneumothorax involves making another hole that stays open and prevents the pressure from building up in the chest.  Trauma teams and medics often use large needles pushed through the chest in a specific location to vent the pressure.  The classic "sucking chest wound", albeit dramatic, is full of pitfalls.  Remember this, just because the sucking sound is stopped does not mean the patient is getting better. They could develop a tension pneumothorax faster BECAUSE the hole was sealed on the outside. 

Other inside holes that are bad to have include holes to the big blood vessels of the chest, the airway and the heart.  If those holes exist, patching the ones on the outside is not likely to be very helpful. That being said, wound seals can also work okay on bleeding wounds by containing the blood and allowing clotting to take place.   

Trauma Shears, Gloves, tape, cravats, backboards and the kitchen sink.

Trauma shears are heavy scissors used to cut away clothes.  Do this if you have the time. However, If you have a severely bleeding wound to the lower leg and the bad guy is still shooting, get to cover and then apply the tourniquet near the upper thigh on the same leg.  Its like I always quote, "Don't just do something, stand there".  Just because you can doesn't mean you should. 

Gloves = Personal Protective Equipment - don't touch a patient without them - ever.  Enough said. 

The IFAK is not a full service first aid kit. It is a "survive the next 10 minutes kit".  

The last two items are meant to be silly.  Backboards are too long to put in a little bag and no one carries a kitchen sink in their first aid kit right?  i have yet to see an IFAK with a kitchen sink, but I have seen "first aid kits" that look a lot like an ambulance in a backpack.  The IFAK came out of a very practical need to save lives during combat.  The IFAK needs to be small enough that each soldier would carry it everywhere and still address the life threats that occur in the few short minutes after a body is hit by things that make holes.  IFAK's aren't meant to treat heart attacks, or splint a fracture.  They aren't any good for asthma or bee stings unless you put the right medicines in them.  The technology in an IFAK represents a major advancement in first aid. Countless lives will be saved in the future through the use of these simple items.  Get your own IFAk and keep it handy.  As our world continues to breed violence, the need for IFAKs will continue to grow.  Get yours today and become part of the solution!

Dr. Matt Evenhouse (doc1@medsecintl.com)