Tactical Combat Casualty Care — Jon S. Solberg, MD

Sadly, everyone these days should have a basic understanding of providing care under fire. Think about the mass shooting at the country music festival in Las Vegas. Lessons learned from ground combat in Vietnam and the Middle East have taught us that some life-threatening injuries (extremity hemorrhage, collapsed lung, and airway obstruction) can be temporarily corrected in the field with minimal equipment and minor interventions.

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In 1993, the US military formed the Committee on Tactical Combat Casualty Care (TCCC) to address potentially preventable combat deaths. Their guidelines, entitled Tactical Combat Casualty Care in Special Operations, are now followed by all branches of the US Military and many SWAT teams, police departments, and first responders. Sadly, we live in a world where all citizens should have a basic understanding of combat-associated injuries and the three stages of Tactical Combat Casualty Care: 1) care under fire, 2) tactical field care, and 3) evacuation of the injured

Stage 1: Care Under Fire

First, win the fight! Providing care under fire refers to aiding an injured person while still in harm’s way. All efforts must be aimed at preventing further injury and stopping the threat. An injured person can be encouraged to crawl to safety, return fire, call 911 from a cell phone, or keep a sharp eye out for other threats, such as a “second-device” (an unexploded piece of ordinance which may be on a timer or remote trigger) or another shooter.

If the victim is on fire, he or she must be quickly extinguished: “Stop, Drop, and Roll” is the most expeditious method, but dirt, water, or any form of fire retardant can also be applied.

Stop life-threatening hemorrhage if tactically feasible. You can encourage the victim to apply self-aid or you can apply a tourniquet to a bleeding extremity. Quickly tighten the tourniquet until blood flow stops and then move to cover. If the location of the bleeding isn’t amenable to a tourniquet, apply direct pressure and a hemostatic dressing (more on these later).

Healthcare providers who are used to the ABCs should note that during the care under fire stage there is no time to address any airway or breathing problems, nor is there any attention paid to protecting the cervical spine. Get to safety! Win the fight!

Stage 2: Tactical Field Care

Assume that at any moment, the threat could re-appear. A confused team member may give away your hidden position or become the threat if he or she isn’t now disarmed. There is a short time to evaluate wounds and equipment is still limited to what you are carrying on your person.

Massive Hemorrhage. Any life threatening hemorrhage must be immediately addressed. Apply a tourniquet or use a hemostatic dressing if appropriate.

Airway. If the victim is unconscious, roll him or her into the rescue position, on his side, so that vomit and secretions will drain from the mouth. In a conscious person, a nasal airway may be inserted into the nose. In an unconscious person, the tongue may be firmly pulled out of the mouth and safety pinned to the lower lip or an oral airway can be inserted into the mouth.

Breathing. Severe breathing difficulties in conjunction with any wound on the torso are assumed to be caused by a tension pneumothorax: the lung has become deflated inside the chest cavity, air accumulates between the lung and the inner chest wall, and each successive breath forces more air into this enclosed space, eventually squishing the heart and lungs so that they can no longer function. The pressurized air must be released. This can be accomplished with a needle decompression of the injured chest wall, by inserting a large needle perpendicular through the skin and into the chest cavity, traditionally about 3 inches below the clavicle (collar bone) on the front of the chest. In an austere or hostile situation, any small sharp object can be used, even the blade of a Leatherman. A good Wilderness First Responder course will cover this procedure in detail.

Circulation. Look for hidden signs of bleeding by performing a “blood sweep.” Run your hands all over the injured person, including in the armpits and the groin. If necessary, apply a tourniquet or hemostatic dressing. Re-examine any previously placed tourniquets and adjust as necessary. In a normal hospital or civilian ambulance setting, direct pressure can be applied to stop bleeding, however in the tactical or austere situation, that takes the care-taker out of the fight and he/she is no longer able to care for other injured persons. Thus, what would normally be a last-ditch effort becomes first line treatment in a tactical situation.

Stage 3: Evacuation

Evacuation can be coordinated by a professional ambulance service or coordinated by the individuals involved in the incident. Hopefully, a pre-expedition or pre-trip planning session has already determined the closest medical facility or a location which is accessible by helicopter or ambulance. If you subscribe to a third-party rescue service, they should be notified as quickly as possible. If abroad, you should notify the appropriate embassy.

Improved First Aid Kit (IFAK)

TCCC trained soldiers each carry an Individual First Aid Kit (IFAK) which contains a Combat Application Tourniquet (CAT), an elastic bandage, a roll of 2” adhesive tape, a nasopharyngeal airway, a pair of exam gloves, and a hemostatic (blood clotting) dressing. These kits can be purchased at a quality sporting goods store, ordered online, or assembled piecemeal.

No one should carry a firearm (hunting, sporting, or concealed carry) without also carrying an IFAK, or at least a tourniquet and combat gauze.

Buy an IFAK from ITS Tactical