Tactical Combat Casualty: What To Do When the Enemy Outvotes You....

(In a previous article, back in March, I touched on the Care Under Fire phase of Tactical Combat Casualty Care. This article is an expansion and continuation of that, based in large part on questions that have arisen when teaching this in recent classes.)

What is Tactical Combat Casualty Care/CUF/TC3? Why should I give a fuck about it?

Tactical Combat Casualty Care, hereafter referred to as TC3, is the current doctrinal protocols for providing emergency medical care to wounded warfighters on the battlefield. TC3 has improved the survivability rate of wounded warfighters exponentially. What body armor has done to wound reduction, TC3 has done to wound survival. It's been, in a word, miraculous.

In World War Two, 19.1% of wounded American fighting men died of their wounds. In Vietnam, that number was reduced to 15.8%. In GWOT, it has been 9.4%! While some of that is attributable to the difference in wound types, thanks to body armor, we are seeing a lot of previously unsurvivable wounds, such as amputations, survive.

Almost two decades ago, in 1996, the Special Operations Command Medical Board developed a report and suggested the first set of TC3 protocols. They were instituted almost immediately within the community. The DoD as a whole didn't recognize them, and establish the CoTCCC until 2000. By 2005, everyone in the U.S. military was on-board. TC3 is used by all branches of the US DoD, all NATO and other allied nations, and many LE agencies have transitioned to it to one degree or another.

You should give two fucks, because knowledge of how to perform it WILL help you and your buddies survive if you are wounded in a gunfight.

What about civilian first-aid or EMT training?

Civilian training focuses on getting you to a trauma ER inside the "Golden Hour." On the battlefield, you may not be able to be evacuated for days, let alone inside an hour. Civilian sector care is predicated on the ready availability of well-trained, experienced surgeons, with a large support staff, and the latest cutting-edge medical equipment. On the battlefield, YOU are the expert! You need to know how to treat the most common types of combat-specific injuries and wounds. It's not just band-aids and aspirin. Even so-called Wilderness First Responder courses too often are not at all suitable for the combat-centric applications that will be required in the coming hostilities.

There are several critical considerations that affect the difference between civilian pre-hospital trauma care and battlefield trauma med. These are:

• the presence of people trying to fucking shoot you!
• darkness (especially for the resistance, the ability to fight effectively at night, with or without NODs, will be critical. Ever tried applying a bandage in the dark? Now think about applying a tourniquet to your best friend, as he's screaming and bleeding out, knowing you can't turn on a visible light, or you'll get shot too!)
• environmental extremes (especially so in wet or cold weather...How easy is it going to be to locate a dangerous wound under extreme cold-weather clothing?)
• obvious different wounding mechanisms (while urban and even rural EMTs do deal with gunshot wounds, the types of gunshot wounds they deal with tend to be different. A .30-06 hunting round makes a significant hole, but it's a lot less severe than five or six holes caused by 5.56 or 7.62...).
• limited equipment (how much shit can you really carry?)
• requirements of tactical movement and maneuver (good medicine is often bad tactics and vice versa...Which is going to take precedence in your situations?)
• long delays to hospital or advanced care (Are you going to have the option of dropping your Ranger buddy at the local government-run hospital? Does your network include professional medical providers and safehouses that can be turned into field hospitals if necessary? How soon can you get there?)

How good is it really?

The 75th Ranger Regiment (yes, my alma mater) trains every single Ranger in TC3 as part of the selection and assessment process. The overall rate of preventable death in battlefield casualties, Army-wide is 24%. In the Regiment, it is currently at 3%. That is the lowest rate of preventable combat deaths EVER reported by ANY unit in the ENTIRE HISTORY OF THE WORLD!!!! This was accomplished by training every swinging Richard in the Regiment in TC3.

Simply put, with proper training, TC3 provides the operative, whether conventional force military, special operations military, or unconventional resistance, with a simplified set of guidelines to initiate and provide the proper steps of care to provide life-saving medical care on the battlefield in a tactically sound manner that allows the successful completion of missions while still allowing for the maximal survival of individual operators who receive critical wounds in combat.

Basic Management Plan for the Care Under Fire (CUF) Phase

This takes place when the enemy is still engaging the unit with effective fire. Both the casualty and the care provider are in harm's way and at risk of being wounded by enemy action. The first priority here is to win the fight, in order to prevent the casualty from being further injured, as well as to prevent anyone else from being wounded or killed. The best medicine on the battlefield is fire superiority! The firepower represented by the weapons of caregivers and the casualty may be essential to dominating the fight! The foundational concept of CUF is that when hostile fire is inbound, not only does it have the right-of-way, but the only way to survive is to focus on returning fire and killing the enemy, rather than playing doctor.

1. Take cover and return fire! The best way to save a casualty's life is to stop the enemy from killing him! Just because you've been shot doesn't mean you're out of the fight. If you know you've been wounded, you're going to survive, if your buddies know and practice TC3. Quit being a pussy and kill the enemy!
2. Direct the casualty to continue engaging the enemy if appropriate/possible. If you MUST move a casualty to cover, consider the following issues: where is the nearest cover? What's the best way to move him? How big is he? Can I move him? Can the rest of the element provide suppressive fire? (At this point in a class, I demonstrate and have the clinic/class participants practice: one man drags, two man drags, two-man carry, and Hawes carry).
3. Direct the casualty to move to cover and perform self-aid if possible (if he can respond to your commands/guidance, he is probably capable of providing self-aid and returning fire. If you get no response at all, it may be necessary to move to the casualty and assess/assist).
4. Casualties should be extricated from burning vehicles/buildings ASAP, and stop the burning process (this obviously is the exception to the rule of focusing on returning fire prior to worrying about saving the casualty. If dude is in a vehicle or building on fire and can't get out on his own, he will be dead before the fight is over. Get him out while the rest of your element provides suppressive fire).
5. Defer airway management until the Tactical Field Care Phase (TFC).
6. Stop life-threatening hemorrhage if tactically feasible. Laboratory studies and battlefield evidence have demonstrated, an untreated arterial bleed will kill you in 3 minutes or less. You will probably/generally lose consciousness in 60-90 seconds. Stop arterial bleeding ASAP! Keep your TQs readily accessible, not buried in a fucking IFAK pouch! I keep one on my war belt and one taped to the stock of my rifle. If I need a TQ, I'm going to have it in a hurry. Expedient TQs are an option, but they MUST be applied correctly. Don't waste time on TQs for minor bleeding. If that shit isn't pumping/pouring out, don't sweat it until after the fight. (I run CAT-Ts and recommend them to everyone. The only other TQ currently authorized/recommended by CoTCCC is the SOF-T, and I know a few SOF docs who swear the CAT-T is better simply because it's easier to apply under stress. I've actually considered switching over to the TK4s, but can't bring myself to trust the effectiveness of a tourniquet that doesn't have some sort of windlass device. In that case, I'd just as soon use a fucking shemagh and a stick...)

• For life-threatening hemorrhage to non-extremities, the current protocol is to apply QuickClot-brand Combat Gauze, with direct pressure for at least three minutes (kind of limits its applicability in the CUF phase...), then apply a battlefield dressing, such as an Israeli Battle Dressing (IBD) or H-Dressing.

Basic Management Plan for the Tactical Field Care (TFC) Phase

This phase takes place after the fight is won. It may also take place in the event of injuries sustained in the field while not under enemy fire. This is NOT civilian sector pre-hospital lifesaving techniques. The use of some of these techniques in a civilian injury setting may get you in a metric shit-ton of trouble legally. I am NOT legally certified or licensed to teach this shit in the civilian world, so if you do use it, and subsequently get sued as a result, do NOT try and call me as a witness. I WILL lie my ass off, even under oath! ("Hell no I didn't teach that dude anything! I've never seen that motherfucker in my life! Tactical Combat Casualty Care, what? What the fuck is that? Some sort of video game? That, of course, is assuming the process server can even find me to serve the summons...)

1. Casualties with an altered mental status should be disarmed immediately (chances are, he may resist this. Convince him to give you the weapon willingly in order to prevent further mental distress. "Hey bro! Let me hold your rifle while the doc checks you out!")
2. Airway Management

• Unconscious casualty with no airway obstruction
• The first option is the chin-lift/jaw-thrust maneuver just like you learned in your Red Cross First-Aid/CPR class. Second option if that is insufficient or impossible is insertion of a naso-pharyngeal airway (At this point in a class, I demonstrate NPA and method of insertion). The NPA may be referred to as the "nose hose" or a "nasal trumpet." (lubricate the NPA if possible. Insert with rotating or back and forth motion, and at 90 degrees to face, not up into the nose. Tape it into place).
• Place the casualty in the recovery position.
• Unconscious or conscious casualty with an airway obstruction or an impending airway obstruction (We're not talking about a dude choking on his fucking chicken nuggets here. We're talking about a dude who just had his lower fucking jaw and face shot off. Don't think it won't happen. The only time I've ever performed an actual surgical chric was because a Northern Alliance fucker took a sniper round through the side of his face. It blew his whole fucking phase off from the base of the nose to his chin. His nasal passages and the upper portion of his throat were FUCKED UP! I was digging out an NPA when my senior Delta looked over at me from treating another casualty and went, "Fuck man! Just stick him with a chric!" Dude lived, although when he came back to the front, he was an UGLY motherfucker!). The first treatment options are the same, but if they are unsuccessful, move to a surgical chricothyroidotomy. Fortunately, it's a stupid simple maneuver. Ideally, it's performed with a scalpel, intubation tube, and a BVM bag. In a pinch, you can do it with a pocket knife, ink pen or car key (or even your finger), and it'll work. Not very sterile, but then again, neither was the fucking projectile that blew his goddamned face off! We'll get to that in a bit. (At this point, I will demonstrate and explain how to perform a surgical chric. Longitudinal cut is preferable to a transverse incision)

3. Breathing

• If your casualty suffered any penetrating or blunt force trauma to the upper chest, upper back, neck or face region, you HAVE to consider the possibility of tension pneumothorax. (This is the development of an increasing air space inside the chest cavity outside of the lung. It generally leads to a collapsed lung and increasing pressure on the opposite lung and the heart, impeding their function...that means the casualty will die if left untreated). Indications are: the aforementioned, followed by increasing inability of the casualty to breathe (no shit?). It's REALLY, REALLY simple to treat also (remember, the average combat life-saver is a 19-year old infantry private with a public high school education...). The doctrinal treatment is the insertion of a 3.25-inch 14-gauge needle into the second or third intercostal space, on the injury side (this is important. Don't do like a dude did in a recent TC3 class I was teaching and point at the OPPOSITE side of the chest as the insertion point!)
• Treat any open/sucking chest wounds with an occlusive dressing. There are a bunch of cool chest seals out there on the market. Asherman devices (invented by a SEAL corpsman), Bolin chest seals, etc...We used to teach and use the expedient flutter valve device. The 2011 protocols and the 2012 instructor guidelines insist that neither has been proven more effective than a simple occlusive dressing. The only time a penetrating chest wound needs to be treated with an occlusive dressing is when the opening is 1/2 inch or larger in diameter (of course, if dude took a .50BMG 0r a 12.7mm round through the chest, you're probably better off not wasting time trying to treat the dude who just got his entire spine blown out....), or there is pink blood frothing around the wound. Otherwise, just dress the wound and monitor for tension pneumothorax.

4. Bleeding

• Assess for any previously unnoticed/untreated hemorrhage and treat it. If direct pressure and/or a simple bandage won't treat it, be more aggressive, and go to Combat Gauze, or other methods (it may come to the point of getting a hemostat locked onto the bleeding vessel to staunch blood flow, but that is certainly something to be hollering "Medic!" for...
• Wounds to the torso should be treated with HemCon agents and/or direct pressure (Again...ONLY QC Combat Gauze is currently accepted by CoTCCC, but a LOT of SOF medics are insisting that it's not the wonder cure it's made out to be, and that simple compressed gauze packed in the wound is often as effective under field conditions). The DoD currently fields a device called the CRoC, or Combat Ready Clamp, for treatment of lingual region penetrating trauma that tourniquets and Combat Gauze alone don't do much good for. I've seen videos and been told it works pretty well. I wouldn't begin to know where to get one. Sorry. Your medic will be able to perform some procedures to try and remedy this, but remember what happened to Corporal Jamie Smith, 3/75th Ranger during the Battle of Mogadishu in '93, when he took a round that blew out his femoral artery in the sublingual region. Despite the best efforts of the medic, dude bled out because they couldn't close the artery. Chances are, you're going to die. The only real alternative for the non-medic is direct pressure on the artery, above the lingual tendon...shove your fist in, lean all your bodyweight on it, and hold it until the medic gets the bleeding stopped, or the casualty dies (I should note that I've never used this method in the real world, nor have I seen it in any of my references. My team senior D showed us it once and swore it would work....)
• Re-assess any tourniquet applications. Replace if necessary. Remove if unnecessary and replace with dressing/pressure dressings.

5. IV Access

• Establish an 18-gauge catheter IV access/saline lock (I ALWAYS explain/demonstrate this if I can get a volunteer, and generally get everyone in the class to perform it at least once, assuming adequate resources exist in their medical supply kits). If fluid resuscitation or access is needed but IV cannot be established, establish intra-osseus access (that's an SOF ATP level skill that I don't have, sorry).

6. Fluid Resuscitation

• Assess for hemorrhagic shock, altered mental status (absent TBI), or weak/non-existent radial pulse. These are the BEST field indicators of shock. A BP cuff is great....in a fucking hospital. When there's a lot of ambient noise (gunfire, guys yelling and moving around a lot, shit blowing up, helicopters landing or taking off) it sucks monkey dicks.
• If the casualty is not in shock, no IV fluids are necessary, and he should be made to drink all the water he can/will take orally.
• If the casualty is in shock, the current ideal in TC3 is a 500-mL bolus of Hextend, followed by another 500-mL in half an hour if he's still in shock, with absolutely no more than 1000-mL. Hextend is approximately 7 times more effective than Ringer's Lactate or Normal Saline! There's only two major issues with Hextend for our purposes...a) you can't find it on the civilian market (at least I can't....), unless you're a trauma emergency room, and b) it costs around $1100 for a 500-mL bolus! For us mortals, the next choice is Ringer's Lactate, followed by normal saline. You can buy these at the local farm/feed store typically, because ranchers use both to treat livestock...I've received a shit-ton of fluid resuscitation from LR and normal saline. It works pretty well. Of course, I never received it due to traumatic blood loss, but if it's all you've got access to, it worked really well for a long time before Hextend came on the market (don't drink LR or saline. They're not poisonous to drink by any stretch, and it WILL rehydrate you in a hurry, but it tastes like ass!)
• You can use as much LR or NS as you need to, based on how much you have in your unit's loadout, but you need to consider the tactical situation. How bad is the guy, is the resuscitation going to make or break his survival? What are the chances you're going to need those IV fluids for a survivable casualty later in the operation? It's called triage. It's a motherfucker, but it IS critical.

7. Prevent Hypothermia

• Replace wet clothing with dry. Get the casualty out of the elements. Create a heat source for the casualty if necessary; have his Ranger buddy (IN DRY CLOTHES OR NAKED) cuddle up next to him to provide body heat, get him into a shelter next to a fire or stove, etc. Cover him with a casualty blanket. (Those little aluminum blanket things you find in the sporting goods section at Wal-Mart ARE NOT casualty blankets. Hell, they don't even work well for emergency body heat for non-injured personnel! Casualty blankets are quilted, with mylar on one side, so they are more heavy-duty)
• If you have to provide IV fluids, have someone stick them inside their shirt to warm them first! (It would really suck to stick a casualty for shock prevention only to have him go into shock instead from the fucking effects of hypothermia!)

8. Penetrating eye trauma

• Any basic first aid course should teach you how to dress a penetrating eye trauma casualty. (Here is a VERY important, super-secret squirrel, classified above super-duper-top-secret, need-to-know, level atomic Special Operations Forces method for treating penetrating eye trauma: WEAR FUCKING EYE PROTECTION!)

9. Inspect and dress any known wounds. Inspect for further unidentified wounds and treat them.

10. Provide analgesia as possible.

• Oral analgesics as possible. The current protocol is 15mg of Mobic (an NSAID used for treatment of arthritis of all things...), and 1300mg of Tylenol (NOT aspirin or ibuprofen! They are blood thinners and anti-coagulants!) self-administered as soon as possible after the wound, if needed. Neither will affect mental status (People always ask me, every class, about using Percocet or Vicodin, etc....Do you really want to give a pissed-off, injured guy, with a gun, something that will alter his mental status enough that he shouldn't even be operating a motor vehicle? Seriously?)
• The current protocol for non-oral analgesics are outside my ability to provide guidance on since they are all script stuff...

11. Splint any known or suspected fractures.

• I generally demonstrate/explain the SAM splint (and recommend them!) and the use of expedient splinting methods, including using the individual's weapon as a splint, if necessary (if it's necessary, make sure you take the obvious step of unloading and clearing the weapon first....).

12. Prophylactic anti-biotics.

• The world is a nasty, dirty, disease-ridden place. Battlefields are the unwiped assholes of the world. Any open wound on a battlefield is going to be infected, badly. The immediate use of prophylactic antibiotics is indicated. Current protocols are:
• If capable of taking orally, 400mg of Moxifloxacin.
• If incapable of taking orally, Cefotetan, 2g, in a slow IV push over 2-3 minutes, or administed IM, every 12 hours, OR 1G of Ertapenem IV or IM per day.
• Unfortunately, unless you've got a really COOL family practitioner, are fucking a pharmacist, or your daddy is a doc, you probably don't have a ready source of script antibiotics. I've got two suggestions: a) try ordering them from overseas through the mail. Thanks to the efforts of AIDs activists, that will no longer get you in a shit-ton of trouble, unless you try to sneak some narcotics in as well, or b) revert to the survivalist stand-by of animal anti-biotics, such as fish antibiotics or what you can find at your local vet store.

13. Treat any burn injuries.

• Stop the burning. Should be done long before you get to this point in TFC...
• Cover the burn area with clean, dry dressings. For burns over more than 20% of the body, cover the casualty with a casualty blanket to prevent hypothermia (I know, it sounds ridiculous, but it's critical. Their body's ability to thermo-regulate just went all to shit.).
• Do not treat a burn victim. Treat a trauma casualty who has burn injuries. All TC3 protocols can be administered through/on the burned skin of a casualty.
  14. Communicate with the casualty throughout the treatment process.
• Explain what you are doing and why. Encourage the casualty. Pay attention to your body language and facial expressions when in the line-of-sight of the casualty.
  15. Cardiopulmonary Resuscitation
• "Resuscitation on the battlefield for victims of blast or penetrating trauma who have no pulse, no ventilations, and no other signs of life will not be successful and should not be attempted."
  16. Documentation of care.
• Document whatever care you provide, so that when the casualty DOES arrive at a safehouse or underground medical care facility, the caregivers there know what has been done to the guy. Don't rely on passing the word on orally from one handler to the next through the auxiliary transportation network...

This IS not a "how to perform TC3" textbook course. Just reading up on this shit and watching videos on YouTube ain't going to get you there. If you own a firearm and ever intend to use it in the anti-personnel role, whether as a member of the resistance, or even just in rural home defense, you NEED to learn these skills! Find an instructor or course and take it. Take the money you were going to spend on your next rifle and get the medical training instead. Put together Individual-First Aid Kits/Blow Out Kits (IFAK/BOK) for yourself, every member of your family, and all of your team/network. NEVER, EVER use your medical gear from your IFAK/BOK on anyone else (In my family, I have two IFAK/BOKs--one on my warbelt, and one on my EDC bag-- HH6 has two--the same--and the morale officer even has one on her diaper bag....seriously)