What I learned by Playing a Victim in a Live Shooter Training - Info for Writers

Fake blood coagulates like real blood 

It's not how every girl likes to spend her Saturdays; but for me as a citizen and as a writer, it was awesome! I was a volunteer victim at an army base. The responders there were training trainers from other states in how to set up live shooter response courses.

How did I get involved?

I'm a member of CERT and a member of the Medical Reserve Corps (for mental health). To read more about these learning opportunities, read THIS ARTICLE. When a call goes out for volunteers, I do my best to show up. As a matter of fact, I'm scheduled to be in a plane crash in April. Stay tuned for more about that.

Why is it important to have live victims involved?

To be clear there were live victims and there were manikin victims. The manikin victims are created to allow tracheotomies and other invasive procedures. They are also severely wounded -  bi-amputations, perforations of the cavity with intestines dangling out. They have robotic aspects to mimic (via radio command) breathing, gurgling, screaming etc. But these are still plastic. 

It is important to remember that responders are human beings. When human beings are faced with a dangerous situation their bodies respond, like all bodies do, with an increase in adrenaline (among other hormones). Adrenaline messes with your body. In a situation like the one we presented, one would expect such things as:

• clumsiness and loss of fine motor capability
• tunnel vision
• distortions of time
• distortions of sound
• difficulty thinking and processing.

What researches have found is that newer experiences have a more profound impact and that an individual can handle the situation better if they've dealt with it before.

Hence,  we volunteers are moulaged (more about that in a second) to make it look like we've sustained a wound, and we act our part. We are in shock. We scream. We fight. We pass out. Basically, it's our job to present as if this were really happening so that it's not new to responders when they show up at a real-deal.

For this training, we were mimicking a live shooter event inside a dorm.

My assignment was to be stabbed (or shot) in the throat - the responder wouldn't know, and I couldn't tell them. 
LET ME BE CLEAR - I was not actually injured. I was never in any danger.

Getting into character - moulage.

Moulage is a word that means making fake wounds for responder training. There's an art to it. This is how they made my neck wound.

1. They came around and smeared spirit gum on the areas of our wounds (there were 18 of us 9 men and 9 women. The men were given the abdominal wounds. 8 of the women had arm and leg wounds. I had a neck wound.)
2. They next came around with liquid latex that they smeared on and let set.
3. The third pass was with a small spatula that crafted the latex into the wound with "raised flesh" around the periphery.
4. Below is a picture of stage 4 
   
   where they painted on theatrical makeup in red and blue to form the base of the wound.
5. The next step was to smear on an unctuous gel that gave the wound depth.
   
   it didn't look at all like a surface scratch but a deep wound.
6. They used a spatula to apply liquid blood that ran freaking everywhere and coagulated in my hair.
   

Getting the heck out of there. Here are some writing points that I picked up to share with you:

• They manipulated my limbs with my clothing. That is, they gathered and pulled my legs and feet with the cuffs of my pants. My arms were moved by the sleeves of my shirt. When they did this the cloth from my clothing supported my whole limb rather than say dangling from and ankle or a wrist.
• When they were moving my body into a straight line, they used the waist band of my pants to get a grip on my center. Again, this felt more stable as the cloth supported my hips rather than putting hands on either side and lifting. It meant that I would not slip out of their grip
• While being manipulated by my clothing, I wished my clothing choice had been a little tighter. My pants were scooching down my hips.
• They used a carrier that was basically a piece of cloth with handles. This allowed them to get me around corners with a great deal more ease than a flat solid board.
• To place me on the carrier, they rolled me in one direction - this was a two person deal, and they used my clothes to manipulate me. They then shoved the cloth under me and rolled me back. Lastly, they adjusted me onto the middle. 
• While they were rolling me, they were also searching my body for any other wounds. They were especially looking for an exit wound. Not finding an exit wound seemed to ramp their concern and upped my level of care. 
• There are 4 levels of triage (rudiments of the stages to give you a flavor). These are indicated by tying a piece of colored plastic ribbon on the wrist (if there is a wrist). I was red tagged.
• black = dead or beyond hope
• red = life threatening first to get response
• yellow = wounded but stable and needing assistance getting out.
• green = wounded but ambulatory
• I have hair that falls below my shoulders. When they placed me on the carrier my hair fell over the end, and it got stepped on. Who knew that could happen? In the grand scheme of things, it was so minor.
• It took 4 people to get me down the three flights of stairs: one at my head, one at my feet, and one on either side of me. They began with just 2 people one at the top and one at the bottom of the stretcher. Quickly, others joined in to get me out -- I was gurgling and needed a tracheotomy.
• On the stairs, the angle to get me down meant that I was sliding out the bottom. They had to both lift my weight and push the sides in to keep me from sliding down the fabric. The guy at the bottom had the biggest trouble. Well, now that I think of it, the guy at the top wasn't so easy either. The guy who lifted my head had to lift me high enough that I wasn't clunking my head down the stairs but not so much that my airway was cut off or that my body slid toward my feet. My head never clunked, during either of the two scenarios they ran.
• When we were not going down the stairs, they slid me down the hall rather than lift. This saved their strength for those three long flights.

Me and two of my CERT pals, catching our breath and regrouping before we went back in the dorm and let the heroes (both males and females) save us for a second time. Mel, on the right, had a sucking chest wound so he was red tagged too. He seemed to be handling the discomfort pretty well. (Big thank you to Mel for sharing his photos) And Anna had a severed artery so she was passed out the whole time.

And that was my adventure - bet it shows up somewhere in my next plot.

Find similar articles under the tab at the top of this page marked "TO THE RESCUE."

As always, a big thank you ThrillWriters and readers for stopping by. Thank you, too, for your support. When you buy my books, you make it possible for me to continue to bring you helpful articles and keep ThrillWriting free and accessible to all.

Code Blue: Information for Writers with Sarah Clark

______________________

_______________________________

A CODE BLUE is defined a cardiac or respiratory arrest.

Here to help us understand what

happens during a CODE BLUE is Sarah Clark. 

Sarah spent 29 years as a nurse. Her positions included: ICU, Emergency Department, Med/Surg, telephone triage, long-term acute care, and teaching at the nursing school. For the last 3 ½ years, she has been the simulation coordinator for hospitals.

If you are writing a crisis that begins outside of the hospital, most likely the patient will be arriving in an ambulance.

Prior to arriving at the hospital the EMS will have sent a bullet-ed report to the CHARGE NURSE. 3-5 minutes before arriving they will encode – this is the report/notification.

At the beginning of the shift, the charge nurse will have assigned rooms within the Emergency Department. Emergency is now called E.D. not E.R. by hospital staff. 
* Your lay person would probably still call it the E.R. 
* It would be a mistake to have the doctors and nurses call it that
   now. 
The charge nurse is on the radio and manages the room flow. The charge nurse will assign the case to a room. 

When the EMS unit brings the patient in, they go straight to their room/nurse.

If they coded on the scene or in the ambulance, several things are already in place for the hospital staff.
· The patient will have pads already in place (often, one on back
   and one on front) for performing shocks and be on a backboard,
   facilitating CPR compressions. 

· The patient will be intubated
· The patient will (when available in that locale) have a LUCAS
   unit in place. A LUCAS will perform chest compressions for 
   CPR, leaving the health providers hands free for other things. If
   the LUCAS is in place, they will most likely leave it at the
   hospital until the patient is no longer in need. It has a battery and
   can operate for around three hours without be connected to a
   power source. It can be plugged in and many ambulances have
   electrical plugs. 

· The patient will have an I.V. line in place.

If the patient comes in with vital signs, then as a writer, you need to decide which of the above you would like to have in place.

Let’s pretend for a moment that a patient presented at the E.D. with signs of a cardiac event. While in the E.D., he codes. Immediately the team goes into action.

Here are the players:

· Medication R.N.
· Airway Manager
· Person Performing Chest Compressions
· Code Cart Manager
· BLS Team Leader - this is the PROVIDER. They no longer call

  the person making the decisions “doctor” with the lack of 

  physicians the provider could be a physician, physician's assistant,
 or nurse practitioner
· Documenter
· Family Guide 

MEDICAL RN stands on the right hand side of the patient. 

· Check for IV access, patency (the quality of being unblocked)
· Establish IV if none present.
· Prime tubing with 1 liter NS (normal saline)
· Administer ordered meds
· Communicate when med has been administered
· Protect the IV site. This is IMPERATIVE. That IV is the patients

   life line in an emergency. If the nurse can not find a vein they

   will place the line in the bone with an IO or intraosseus line. T
   The nurse will say “Drill ’em.” This method is fast and relatively
    safe. 

   VIDEO QUICK STUDY Trigger alert. Graphic. (12:00)
* The IV line is most at risk when the patient is being moved from
   one stretcher to another. GURNEY is a term that is no longer in
   use.

Ambu Bag

The AIRWAY MANAGER :

stands at the top of the stretcher and is usually a respiratory therapist. This is NOT a nurse. A respiratory therapist has an associates degree – a two-year degree in providing respiratory aid.

· Open airway
· Ventilate with Ambu bag 

· Requests suction setup 
· 2 People: 1 to seal the airway and 1 to squeeze the
  bag 

  * An Ambu bag is 100% oxygen. 

  * During a code the patient is manually ventilated. 

· This person will often stand on the left, or if need be, they can get

    right up on the gurney with the patient. This person needs to get

    the chest compressed a full 2” or it is ineffectual. Most people

    will wear out after two minutes and need to be replaced. 

· Any qualified person can do the compressions. 

· They monitor/check for pulse 

· If the patient did not come in with EMS then they will place a

   back board and a Zoll pad (for shocks) there are 2 pads – one on
   the back and one on the front. They can cause fire (chest hair)
   They no longer use paddles.

· Two people can rotate responsibilities to give the person giving

   compressions a chance to rest. They must monitor the quality of 

   the compression.

· Stands next to the cart –  everything they will need during a

  code is in the cart. She will hand people things as they are 

  needed. 

· They must be a nurse, and it is best if they are familiar with the

   layout of the code cart
· They hand in:

  * Back board 

  * Zoll Pads

  * Set up for suction
  * IV tubing with one liter of NS 
· Prepare the Empinepherine 
· Hands in meds as ordered
· Operates Zoll defibrillator
· Communicates with the runner for needed supplies

So for example:
The provider will say, “Give an amp of Epi.”
Code cart manager replies, “Epi.” As she hands it to the medication

                       nurse.
The medication nurse says, “Epi.” Then administers the meds and

                       says, “Epi’s in.” 

BLS TEAM LEADER
· This is the provider (doctor/physician's assistant/nurse practioner)
· Stands at the end of the bed and does not do anything hands on to

   prevent tunnel vision. 

· Needs to be able to see everything
· Makes all decisions about the patient 

THE DOCULMENTER
· Ideally, this is the patient’s nurse – in reality it will be a newer 

  nurse. The documenter stands next to the provider.
· Charting – documenting everything that takes place
· Ensure participants sign the code sheet
· Timer – is UBER IMPORTANT!

“It’s been two minutes. Time for a rhythm check.”

EVERY TWO MINUTES:
· Check the rhythm on the heart monitor
· Check pulse in the femoral area of the groin. That would be here:

· Change out the compressor if they are human. 
· Decide if you are at a shockable rhythm
· Shock them.

“It’s been three minutes do you want another epi?”

EVERY THREE MINUTES:

· Epinephrine helps vaso constrict to shunt the blood to the heart 

  effectively – it is the first line drug to use in a code, and it can be

  administered every three minutes. 

FAMILY GUIDE
· Determines if the family wishes to stay
· Positions the family near the exit
· Answers questions briefly and honestly
· Reminds the team the family is present (tendency towards gallows

   humor to break the stress)
· Escort the family out if needed


In every hospital there is a RAPID RESPONSE TEAM. This is a pre-code team that includes an experienced nurse and a respiratory therapist. They identify the patient’s risk of coding and move him to ICU.

NURSES SAY “CRAP.”

When do they stop?

1) The patient is stabilized
2) The patient is declared deceased
    · Typically, they will call it if the efforts have not worked and 

       the patient flat lined for over twenty minutes.
    · If they were brought in with a flat line, it’s usually called – 

       because of the length of time they were down. 

    · If the spouse/parent is on the way, for example, they 

      will try to continue efforts until the spouse has arrived. 

    · Often it’s the family that asks the team to stop 
    · Sometimes they continue for longer than they normally would

       have to give the family time to come to the conclusion on their

       own. This helps with the grief process. 

And there you have it. 

A huge thank you to Sarah Clark  for her expertise.

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Bullet Tutorial for Writers

.40S&W cartridge next to expanded hollow point bullet. (Photo credit: Wikipedia)

DISCLAIMER - This is a non-political site that is geared to help writers write it right. I am presenting information to help develop fictional characters and fictional scenes. In no way am I advocating any position or personal decision. 




So things got pretty serious. Guns were drawn; a body sprawls on the ground. What the police find on the scene has a lot to do with what kind of bullet you as the author chose for this plot line.

If you need a tutorial about Step One - choosing a gun click HERE

Once your heroine has a gun in her hand, there are other things to consider. Let's begin understanding bullets and how they impact plot.

THE BASICS

* The bullet is just the top piece of the round - the part that hits the
   target.
* A cartridge or round is the entire component 
   (brass + powder + primer) When the primer is hit by the hammer 
   or firing pin, it ignites the powder in the shell, forcing the bullet 
   in the only direction it can go - down the barrel of the gun.
* The caliber is a measurement of the bullet. (If the bullet has two
   numbers the first is the width of the bullet the second is the
   length of the round.)
* Another way to measure a round is by grain the higher the grains
   the more the bullet weighs - the slower it goes and the deeper it
   will penetrate.

INTERMEDIATE - How to read a bullet box:

Jackets

*Full Metal Jacket (FMJ) - the entire case is encased in metal,
  offering the most penetration through your  target. The base is 
  exposed showing the lead.
*Total Metal Jacket - (TMJ) - The entire case including the base
  is covered
*Semi-jacketed (SMJ)- or just (J) for jacketed - the jacket only
  goes half way up the bullet.

Tips

.22 hollow point     9mm hydro-shock      9mm FMJ round nose/tip

Flat Point - (FP) has a flat tip (pictured below - left)
.
Round Nose - (RN) (below center) - This bullet will not expand in
      size with impact; it will continue on its trajectory. 

      This is an author's decision if she wants the victim to have an 
      exit wound, to die of impact/blood loss, or for the bullet to hit a
      secondary object or person. All of these would could result
      from a RN Click HERE to go to my blog article on Blood
      Spatter.

A cut-through of a hollow-point bullet.  (Photo credit: Wikipedia)

Hollow point -(HP) the tip is hollow. When it hits its
      target it will expand very quickly to almost 3x it's 
      original size. This means that the bullet expresses 
      the power inside of the body, damaging more 
      tissue than a round nose bullet. This expansion 
      also reduces the chance of a bullet exiting the 
      body and hitting someone nearby. This is safer 
      for self defense where innocent people are 
      nearby. This type of bullet creates massive pressure
      and the victim is likely to die of a brain embolism.
      Click HERE to go to my blog article on EMS and
       gunshot wounds.


Video quick study: First Science TV Round Nose v. Hollow Point (2:08)

9mm flat tip                     9mm round tip                    9mm hollow tip
 (Photo credit: Wikipedia)

ADVANCED - Information about calibers

Baby Bear

.22 is cheap so it's good for target practice, but has minimal penetration - not great for defense.

Video Quick Study (5:56) This is a little in depth but shows him weighing the bullet (grains) and measuring the bullet for caliber, and also ballistic tests through testing medium.

.25 is used in small pistols it has a big kick - so a lot of recoil.
.32 penetrates a little deeper than a .380 and has less recoil  
.25 for a very small gun this is a good self-defense round

Mama Bear

38s and 9mm are the same size bullet. One is calculated in inches, and one is calculated in metric.The three kinds of 9mm  from smallest to biggest:

.380 Auto vs. 9mm Luger (Photo credit: Wikipedia)

* .380 and 9mm Short are the
   same (9x17) a little more
   power than the 38 special - 
   goes in a small pistol.
* 9mm Makarav (9x18)
* 9mm Luger is also known on
   the box as a
   9mm Parabellum (9x19)
   These are accurate far
   away, up close they are devastating. At 15 to 20
   feet your character might have to hit a guy 6 times
   to stop him if he's drugged up.
   (This is the bullet I shoot in my Springfield)


This is probably as big a caliber as your character needs. But if you are trying to make a decision between giving your character a 9mm or a .45 here is a good comparison video
 9mm v .45 bullet (17.31)

Papa Bear

.40 is the same as a 10mm. But a 10mm is really a .40 caliber magnum (I'll explain in a second) The .40 does not have the penetration of the 9mm because it is heavier and takes more power to shoot.

.45 is highly effective in dropping the target in one shot.

Video Quick Study: 10mm ammo energy test   (7:28) go to 3:50 mark

Rabid Klondike Mama Bear Protecting Her Young -or-What is MAGNUM?

A magnum round is a high powered round. So for example you can have .22 magnum or .45 magnum
* Lots of recoil
* Painful to shoot
* This is for hunting (a back up when an angry bear is running full
   tilt at the heroine) not usually for self-defense.
* IT IS IMPERATIVE THAT YOU USE A MAGNUM IN A GUN
   THAT CAN HANDLE IT -
   The gun must be designed to handle magnum bullets unless of
   course you want your heroine to put a .44 magnum (name of a
   round) or .44 special (name of a round) and blow her gun apart
   because the gun couldn't handle the pressure.

Popular wisdom says, a bullet shot from any handgun at a distance of three feet will probably stop anyone. Most of the time a civilian is shooting, it is that close in range. Stopping power is not as important to a civilian as it is to a police officer whose range moves out to nine yards. So your gun/bullet choice depends on who is doing the shooting and why.

Sonic v. Subsonic Bullets Shot with a Suppressor - 

Brian Coates, U.S. Marine Corp., veteran

LINK Nottoway Shooting Sports

PLOT TWIST - One thing that I should point out is that just because a bullet will load into the gun, it does not mean that there will be success in shooting it. A particular round might misfire or jam. Once you know which gun is being used, research which bullets work best. Though, this could create a plot twist for you. Perhaps your heroine is new to the gun scene and buys a weapon for self-protection, purchases some bullets, loads it all up and there is a catastrophic failure. She could be hurt instead of the villain.

Image publicly distributed source unknown

VIDEO 1 - Bullet Basics 101 (8:01)

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Thank you so much for stopping by. And thank you for your support. When you buy my books, you make it possible for me to continue to bring you helpful articles and keep ThrillWriting free and accessible to all.