Medic Handbook
Last updated
Last updated
As everyone who has turned the wrong corner at the wrong time knows, there is always a need for more and capable medics. By the end of this, I promise you will know exactly what to do to join their ranks.
Going into this, I will assume you have a basic working knowledge of ACE and use the ACE medical menu. You will find explanations and protocol, as well as sample loadouts and raw data at the very end. I am trying to make the inscrutable amount of info with all its variables easily digestible. Failing that, there are step-by-step flowcharts to skip to, which guide you through treatment.
Additionally, I’ve made it a point to verify everything in here with the actual ACE Medical files. Hopefully, we can dispel some of the misconceptions and myths that have cropped up over the years.
The Medic's Good Etiquette You must be assertive, as you will often find a crowd around a body that will do everything in their power to be unhelpful. You are the one who will get a casualty up with maximum efficiency, so make sure everyone knows the boss is here.
To be assertive, communicate effectively. Keep those around you informed; talk to your patient about your treatment. This way, you avoid double-bandaging a wound and overdosing on meds, and send excess manpower back to where they can be useful.
When you arrive at a location, give everyone a quick shout; they might need you. You're a gift from the gods when mortars strike just as much as after a prolonged firefight with many small nicks and scrapes.
This also means that you are indispensable to the platoon’s survival and therefore should keep your head down during engagements. You cannot save anyone when you are dead.
Travel light to remain mobile. Smoke grenades are your best friend when traversing gaps in cover, so if in doubt, bring more of those rather than extra magazines. Keep your supporting equipment sound first.
When sorting through casualties and patients, it's often helpful to start what is called triage. This is when your voice is expected to be heard above all the noise and disorganization that usually ensues when it has come to the point of needing one.
"Everyone, triage! Scrapes and bruises to the battlements and fight, torn off limbs line up here!"
Casualty states are assigned based on trauma level.
P1: severe injuries, likely already unconscious with blood loss and open wounds requiring immediate attention where any delay can prove fatal
P2: severe injuries, but stabilized to the point of no longer requiring unsplit attention, though should be kept in mind for later
P3: light injuries that only just require the attention of a medic after P1s and P2s are dealt with; patients can still walk and be useful if necessary
Deceased: patients beyond help, effectively or actually dead
You control how easily a P1 can be fixed by how quickly you react to a call.
As a medic, you’re called to emergencies, so P1, or asked to remove that nagging wound from half an hour ago, so P3.
A mortar victim with six large avulsions will be dead within the minute, whereas somebody emerging from a crashed Humvee can usually walk it off and talk to you later down the line.
Make mental notes about everyone who comes to see you. The ACE medical menu keeps track of treatments for you, but, as we will see in a moment, bandaging with an elastic bandage is a different matter entirely from using packing or quikclots.
To decide which types of injury dictate what type of reaction, let us move on to…
Avulsion: Tissue forcefully torn away from where it belongs. On legs, they cause a limp even without fractures. A severe type of wound with extreme pain and a high rate of bleeding.
Velocity: Deep penetrating wounds are often caused by bullets. Hitting bone can cause fractures. Very high pain, fastest bleeding.
Crush: Tissue crushed under heavyweights. They can cause fractures and limping. Slow bleeding but great pain.
Laceration: Another tear that separates tissue without carrying it off and away. Moderate pain, medium blood loss.
Fracture: A broken bone. Caused by falling, ordnance, and crashes. On arms, they cause extreme aim shake. On legs, they cause a limp. Extremely painful. No blood loss.
Puncture: Caused by shrapnel or slow-moving sharp objects. Occasionally causes limping. Light pain, slow bleeding.
Cut: Occurs from shrapnel or other sharp objects cutting skin and muscle. Light pain, light blood loss.
Abrasion: A scrape. Slow bleeding, though large ones cause a moderate amount of pain.
Contusion: A bruise. You cannot fix these with bandages, but they also don't lead to blood loss. They can cause moderate pain.
Basic: A medium-effect, medium-sealing bandage with medium delay for your everyday needs. It's the averagest of averages. Use on lower priorities and crush wounds.
Packing: Identical effect to basics, high chance to reopen, but excellent delay until a wound bothers you again. Basically an in-combat ‘fix now, medic later’ solution. A rifleman's best friend.
Elastic: Highest effect, worst chance to reopen, lowest delay. These are great to get through an emergency, but otherwise inefficient.
QuikClot: Lowest effect, lowest chance to reopen, excellent delay. Its low effect means it’s great for small wounds, but needs substantial volume for large wounds; then used in calm situations with a large supply and supplementing packing.
Splint: An instant fix to fractures.
Tourniquet: Stops bleeding by cutting off blood flow to the limb. Becomes painful after 2 minutes. Blocks injections and vitals. Not applicable to the head or torso.
What do effect, reopen chance and reopen delay mean? The higher the effect, the fewer bandages you need to stop a bleeding. Reopen chance is how reliable a bandage is. The lower the chance, the less likely it is to reopen. Reopen delay, here, is the average time a wound stays closed until it reopens if it reopens. Longer is better.
Rule of thumb: work off of the delay instead of trusting in the chance for large or severe wounds.
Here’s a statement that will cause controversy: All bandages are good for all wounds.
The choice is in what you want to achieve in any given situation. You took a bullet, but have to return fire and save your team? Packing bandage. See the medic, but it lasts you until after the heat has passed. A BMP farted in your general direction? Support elastics with tourniquets. Revisit wounds with permanent solutions when stable.
NOTE: Wounds reopen. Apply a QuikClot to a medium+ wound first, then treat the resulting partial wound with another bandage. The QC’s higher chance means you only have a partial bleed to deal with when the bandage on top falls off.
Exception: small wounds don’t need elastics, ever. That said, you can absolutely minimax bandage use.
Tables, a spreadsheet, and other data are presented at the end. For a quick reference to outside emergencies, here is an overview of preferred bandages for each wound.
Light green means viable, white means not ideal, light red means waste of time. Dark green means Editor's Choice, dark red means Stay Away.
To treat someone effectively, you must know what to treat in the first place.
There are three types of vital signs: heart rate, blood pressure, and responsiveness. Pain has cheekily sneaked in here, too.
Heart rate is the number of heartbeats per minute.
Affected by drugs as well as time, blood pressure, and pain.
High: >110
Normal: ~80
Low: <55
Epinephrine to raise it, adenosine to lower it.
Blood pressure is… complicated.
For our purposes, blood pressure most closely relates to the amount of blood you have.
Heart rate plays a role in it, and because pain makes your heart race, pain can also skew the BP value upwards. With most blood loss, BP trends downwards.
The ideal blood pressure is 120/80. This value reads as “120 (systolic) over 80 (diastolic)”.
To learn more about this, here’s a digression in cardiovascular medicine within ACE.
BP is factored in from cardiac output and peripheral resistance[3]. This is indeed simulated in ACE, but we’re going to deconstruct those unnecessarily fanciful words so you can apply it to gameplay.
Cardiac output is a product of your heart rate with total blood volume. Every soldier in Arma starts out with 6 litres of blood.
BP = (Q * PR) * c_x ((BV / BVd) * SV) * HR / 60 = Q, cardiac output, where SV, ventricular stroke volume = 0.095 PR = 100 - fn, where fn is the abstract flow adjust from viscosity and vasodilation (BV / BVd) is the blood volume ratio of current to default Systolic coefficient c_s = 9.4736842; Diastolic coefficient c_d = 6.3157894
Every unit of blood lost decreases the output and therefore blood pressure. An increase in heart rate raises cardiac output and lifts BP. HR goes up as blood volume goes down to compensate for output and keep BP stable. It does this poorly.
Peripheral resistance is the tightness of blood vessels with blood viscosity. Constricting them increases blood pressure, dilating them (here: with medication) decreases it. So far, only morphine has an effect on this.
Do not believe anyone when they say saline thins the blood, nor does plasma thicken it. It is simply not in the files.
End digression.
Pain is the alarming effect of trauma. The more severe the trauma, the greater the pain and the more debilitating its cues.
Pain is linked, but not directly proportional, to the bleed rate of an injury, and causes adverse effects, i.e., aim shake and an increased heart rate. It fades away over 10 minutes and is counteracted by morphine.
Cross the pain threshold and you will fall unconscious. This can happen from one severe trauma or several small ones.
Responsiveness or consciousness is the awake state. If you follow the good medic’s etiquette, diagnosing a problem will happen with your communication: you get no answer.
Unconsciousness can be your first clue that a soldier has been through relative hell. Immediately triage them as a P1.
Unconsciousness always occurs from a cascade of several causes. These are:
Pain knockout from sudden trauma; can resolve on its own.
Can happen from bruises in a car crash, a non-penetrating round to the carrier plate, or avulsions from a landmine.
Treat the cause, then the pain.
Bleeding wounds that exceed half your cardiac output
Too many holes through which blood escapes will overwhelm your heart.
Wounds on limbs bleed slower with concurrent bleeding on the head and torso.
Haemorrhages, aka blood loss.
Class 1 is minor blood loss less than 900 ml that does not yet impact vital signs. - Class 1 expected BP: ~110/80
Class 2 & Class 3 haemorrhages are defined at 15% and 30% total blood loss respectively, or about 900 and 1800 ml of fluid. (“Lost some blood”, “lost a lot of blood.”) - Class 2 expected BP: ~90/80 - Class 3 expected BP: ~72/50
Class 4 haemorrhages at 40% or 2400 ml lost and mere moments away from fatal. (“Lost a large amount of blood”) - Class 4 expected BP: ~54/40
Class 5 are critical cardiac events at 50% loss of blood volume (“Lost a fatal amount of blood.”)
P1 good habit: put on a bag of IV while you work to counteract massive bleeds.
Overdoses
Every medication has a hardcoded overdose threshold that throws the heart out of whack and causes immediate cardiac arrest.
Don’t do drugs, kids (let the medic do them for you)
Cardiac arrest happens when the heart has stopped doing its job. Several things can cause this:
Low heart rate (HR below 20 guaranteed, with a chance to arrest below 30)
High heart rate (HR above 220)
Blood pressure under 50/40 and heart rate under 40 (almost always class 4 bleed, or morphine abuse)
Diastolic blood pressure over x/190
Class 5 (3 litres lost) haemorrhage (hardcoded)
Cardiac arrest always causes unconsciousness and will kill you if you remain in that state for 4 to 6 minutes, unless CPR is applied.
So how do you get out of this mess?
Now that we know what all those words mean and do to you, we’ll learn how to correct them.
You will find and fall into your own groove over time, develop your own system of habits and create your own loadouts to make for the best medic you can be.
So let’s give you a starting point to that journey.
In treating a patient, everything we’ve talked about so far applies dynamically; from communication and triage to bandages and diagnoses.
Diagnosing vital signs seems daunting from that dense bit above, but we have one advantage: pretty much everything you find is going to be caused by (bullet) wounds, and therefore it’s all about blood loss: Bandage wounds, apply fluids as needed.
Medication
You have three autoinjectors to work with: morphine, epinephrine, adenosine.
All of them influence heart rate, and they do so with different magnitudes based on the current heart rate. Their maximum effect after injection is delayed, and then linearly tapers off to zero.
NOTE: Autoinjectors and IV bags are blocked by tourniquets.
Morphine (time to max effect: 30 seconds)
Drastically lowers pain
Reduces heart rate - Low HR: between -10 and -20 - Normal HR: between -10 and -30 - High HR: between -10 and -35
Dilates blood vessels, which drops blood pressure If your patient is critical, do not inject morphine before stabilising them
4 injections to overdose
Lingers 30 minutes
Epinephrine (time to max effect: 10 seconds)
Increases heart rate - Low HR: between 10 and 20 - Normal HR: between 10 and 50 - High HR: between 10 and 40
Hastens wake-up checks when unconscious
10 injections to overdose
Lingers 2 minutes
Adenosine (time to max effect: 15 seconds)
Decreases heart rate - Low HR: between -7 and -10 - Normal HR: between -15 and -30 - High HR: between -15 and -35
6 injections to overdose
Lingers 2 minutes
NOTE: Morphine lowers vitals in three ways. First, heart rate by a flat value as above. Secondly, by dropping BP. Thirdly, by reducing pain, because pain drives up heart rate.
This means that even a healthy soldier gets knocked out by ~2 sticks of morphine, well before the OD threshold. A critical casualty will enter cardiac arrest with careless drug use.
Moving on to IV fluids, these are surprisingly easy to summarise:
Blood, Plasma and Saline equally increase blood volume by the amount it says on the label at 250 ml / min
Blood does not spoil, saline does not thin and plasma does not thicken.
Resuscitation
We have two ways of resuscitation, that is, correcting fatal vital signs: fluid resuscitation and cardiac resuscitation. Any casualty in a state that needs resus is a P1.
Fluid Resuscitation
This is straightforward: if blood was lost, replace it with IV bags. Most often, by the time a casualty has fallen unconscious from blood loss, you’re looking at a Class 3 haemorrhage and therefore over 1500 ml volume loss. Rule of thumb: At most hang 1500 ml to drip at a time. Better check again than waste resources, because IV bags only top off; you don’t get to have spare fluids in your body.
Cardiac Resuscitation When cardiac arrest occurs, you must act quickly. This comes in two parts: chest compressions for CPR, and epinephrine. The caveat is, the heart does not run on fumes. You must make sure blood volume is good first. You find no pulse and blood loss is unlikely? This could be a morphine overdose. It’s more common than you think.
CPR is your first course of action when you find no pulse and the time since arrest is unknown. Apply CPR once to stall death, then hang an IV if necessary while you stabilize wounds, and do CPR every 20 seconds. Call for help here if you find overwhelming wounds.
NOTE: When you take the pulse of someone receiving CPR, it will appear as if the heart is beating at 20 to 35. CPR is not finished unless you find a strong pulse, above 80.
Inject epinephrine to kickstart the heart. Continue CPR until you find a pulse.
NOTE: In game terms, the system has a wake-up chance that checks for stable vitals in 15-second intervals. Epi reduces the time between. You can have done everything right, the game just hasn’t been checked yet. Keeps the tension up, doesn’t it.
Surgery
Wounds reopen. We’ve all been irritated by this before.
Thankfully, medics have a permanent solution in stitching them. This takes 5 seconds per wound to stitch, no matter its size.
NOTE: Careful with elastic bandages before surgery, as their reopen time is so low that they can come off during the animation.
Field Day - Treatment Walkthrough
You've received a radio call for a medical emergency from inside a barn 100 m west of your position with hard contact to your north. The way there is without cover and concealment, but breaking south would offer you some chest-high walls and a bit of defilade to hide behind, albeit at the cost of longer transit.
You have two choices here: Move south to go the long and safe way around, potentially giving your patient's wounds more time to stain the floor red, or deploy a smoke wall to traverse an open field with bullets whizzing past, but being much quicker to arrive.
Ask, via radio, for a quick first assessment. Is the casualty conscious? Critical?
Think fast, or find a mediating factor.
Then book it along your chosen path.
Arriving at the scene means finding the casualty as quickly as possible, opening the medical menu, and taking vitals in one swift motion.
Let me reiterate: A medic should remain mobile first and foremost. Aim to keep your weight low, ideally around 30 to 32 kg.
You’ll find yourself sprinting a lot.
For a baseline, I'm using RHS US Army OEF-CP gear with an Eagle backpack which offers a nice balance of capacity and weight while showcasing what I feel is the minimum you should bring.
This first one sports that full RHS Eagle backpack.
It will get you through most AOs just fine. You are ready for up to three intense emergencies and can comfortably share, but on longer operations, you will ideally have access to a resupply, like an FOB or a vehicle to operate from.
The second one revolves around the vanilla-sized kitbag, which is stunningly roomy and, to me, represents the maximum viable weight when full at 36 kg kit mass.
If this one runs out -- mate, you need to get yourself out of trouble.
For a self-trial, fill that Kitbag and adjust your basic gear to see how low you can go. Lighter rifle? Fewer mags? Lower armour?
Find your niche.
The Mobile CLS
Uniform
Your preferred necessities
Vest: standard or light plate carrier
4 - 6 magazines
4 smoke grenades, white
1 smoke grenade, side colour
1 smoke grenade, purple (casualty marker)
Backpack: Eagle (99%)
12 Basic Bandages
12 Elastic Bandages
15 QuikClots
20 Packing Bandages
6 Tourniquets
6 Morphine
6 Epinephrine
5 Splints
Saline
2x 1000 ml
3x 500 ml
Plasma
1x 1000 ml
3x 500 ml
1 Surgical Kit or +1000 ml plasma
The Ready Man
Backpack: Kitbag (95%)
20 Basic Bandages
15 Elastic Bandages
20 QuikClots
30 Packing Bandages
8 Tourniquets
8 Morphine
8 Epinephrine
2 Adenosine
8 Splints
Saline
3x 1000 ml
4x 500 ml
Plasma
3x 1000 ml
4x 500 ml
1 Surgical Kit
3 Body Bag
1 Banana
To showcase bandages and their exact values, I present to you: a spreadsheet.
This is not a quick reference to pull up for daily gameplay. This is for all the hardcore factmongers out there.
To go along with this table, here is a sheet that outputs the most efficient bandage based on the type and size of wound you put into it:
[Cheat Sheet] ACE Advanced Bandage Evaluation
You can find two drop-down menus in the top left corner for you to manipulate. A couple of calculations later, you’ll be given the best and worst bandages highlighted in a table.
ACE Medical framework PBOs
ATLS Guidelines
Volume and its relationship to cardiac output and venous return
S. Magder et. al., Sept. 2016
European Heart Journal, Dec. 2006 issue
Alicia M. Maceira, Sanjay K. Prasad, Mohammed Khan, Dudley J. Pennell et. al.
Hypovolemic Shock
Sharven Taghavi; Reza Askari., June 2019
7 YeArS oF aRmA
