What is the first step in TCCC?

What’s in this blog post

If you are feeling comfortable with your medical knowledge, you can jump ahead through the sections by clicking on the links below:

Introduction to Care Under Fire

The first phase of Tactical Combat Casualty Care (TCCC) is Care Under Fire (CUF). Care Under Fire is medical attention provided by the first responder or combatant to arrive at the scene of injury during an in-progress firefight.

Typically, in a CUF situation, available medical equipment is limited to that carried by the casualty in his or her individual first-aid kit (IFAK) or by the medical provider in his or her aid bag.

In this blog post, I’ll share my guidelines for successfully working your way through the phases of care in CUF so that you can provide good tactical field care and help your teammates remain engaged in the mission.

Care Under fire Guidelines

1. THE BEST MEDICINE IN A FIREFIGHT IS FIRE SUPERIORITY

You may have heard it said that “good medicine is bad tactics,” meaning that what’s best for the patient might not be best for the mission (because the best military medical care during a firefight is fire superiority).

So you might not be able to start caring for the patient straight away.

At times like that, it sucks to be us (medical personnel) or them (casualties). But this is the life we’ve chosen to live in order to let others sleep peacefully at night. 

If you can, try to perform treatment “stopgaps” such as rolling the casualty on his stomach or telling him to apply self-aid.

Just remember that nothing is written in stone, so everything is scenario-dependent. Still, one of the best lessons that can be drilled into you is to return fire and take cover.

2. WE EXPECT OUR WOUNDED TEAMMATES TO STAY IN THE FIGHT

Not every “BeepBeep” in a firefight gives cause to disengage. If the wound is slight, he stays in the fight. 

3. START WITH SELF-AID

Yell out to the casualty (or send him a radio transmission) and direct him to take cover if you can’t get to him. 

If you are the casualty, don’t just lay there thinking you’re going to die. Force yourself to begin applying self-aid.

4. TRY TO KEEP THE CASUALTY FROM SUSTAINING ADDITIONAL WOUNDS

Preventable combat death means maintaining security and/or continuing to exert fire superiority while making a plan to get your buddy out of harm’s way.

If you or someone else is trapped in a burning vehicle or building, first do everything possible to extricate yourself or the other person and then do what is necessary to stop the burning process. 

Also, pay attention to the airway so that no inhalation injuries come creeping up and catch you off-guard.

Learn more about No-Melt, No-Drip protective clothing in our Reality Check blog post. Read now.

6. ROLL THE CASUALTY ONTO HIS STOMACH, IF POSSIBLE

Generally, we don’t perform airway management in Care Under Fire. This isn’t field-hospital trauma care you’re delivering. However, we can still do a sloppy A (from the M.A.R.C.H. algorithm) as we roll our casualty onto his stomach.

Rolling him onto his stomach helps prevent the casualty’s tongue or blood from suffocating him.

Not meaning to sound matter-of-fact here, but what we are trying to do is buy extra time (while still in an active situation) in order to eliminate the threat so that we can safely come back for our guy and treat him when and as we can.

7. PLAN/GRAB & GO/TREAT

If tactically feasible, stopping life-threatening external hemorrhage is a primary goal during CUF. Otherwise, do as previously mentioned: instruct the casualty to apply self-aid or, if you’re able and can reach some cover, apply aid (including tourniquets) from your own kit. 

In any event, the first thing you must do is get the casualty off the “X”.  You’ll do this by using the Plan/Grab & Go/Treat method.

See  the CUF guidelines in action:

Watch more Combat Medic Essential videos here.

Your plan for tackling this monster challenge will depend on:

• the number of casualties
• who will be providing covering fire/throwing smoke
• the amount of risk for the rescuers
• location of the nearest cover
• the best method for getting the wounded to cover (1- or 2-man team? Vehicle because of the distance involved?)
• size and weight of each casualty (a small, skinny guy needs fewer personnel to carry him than does a tall, beefy dude)

Before executing the plan, try to communicate with the casualty and tell him what you’re about to do so that he doesn’t mistake you for the enemy and open fire on you.

Important note: in the course of executing your plan, try to also retrieve the casualty’s mission-sensitive items. Those include his weapons, communication devices, and the like.

WHAT HAPPENS IF WE CAN’T GET OUR BUDDY OFF THE “X“?

In case we can’t get our casualty off the “X,” we need to think outside the box and figure out a way to make the “X” “disappear”.

Speaking of making something disappear, make sure you read our blog post on The Science Behind Camouflage here.

“I don't want to be a product of my environment. I want my environment to be a product of me.”  —Frank Costello/The Departed 

To avoid the very bad situation of caring for our patients in the middle of a “kill zone,” it’s necessary that we effect a tactical evacuation by getting them off the “X” and behind cover. 

The likely outcome of you treating them inside the kill zone is your own lifeless body will end up stacked atop that of the buddies you were trying to help.

But if we can’t get our patients off the “X”, let’s change the rules and make the “X” disappear. 

How? 

We could neutralize the threat via JDAM, sniper fire, or positioning armoured vehicles between the enemy and our casualty. 

Don’t rely on luck, though. Luck is the dying wish of those who want to believe that winning can happen by accident. 

Chance favours the prepared.

SURVIVAL OF THE MOST ADAPTABLE

Setting yourself up for success is what these CUF guidelines are all about. And to achieve success you need training. 

I’m not talking just about medical training, because knowing only medicine is like knowing how to eat with nothing but a fork (which I suppose is fine when it’s pasta on the menu, although not so much when the meal includes soup).

No, what I’m talking about is training that equips you to provide care in many types of situations.

For example, the same concepts of Care Under Fire apply to treating the victims of a motor vehicle accident.  

First, we take care of ourselves—self-aid if needed. 

Next, we move the injured driver(s) and/or passenger(s) to a safe location. Then we secure the scene so that incoming traffic won’t cause further damage or injury, and we look for other possible nearby threats. 

If you or somebody else is trapped in a burning vehicle or building,  we do everything possible to extricate them/ourselves and do what is necessary to stop the burning. 

Plan how to get your casualty away from the flames. Check if he has massive bleeding or trouble breathing. 

Notice whether another casualty is in the way and if there are environmental dangers involved. 

Pay attention as well to the airway, so that an inhalation injury does not come creeping up on us—and, if necessary, we disregard C-spine precautions because no one will write you a letter of appreciation for an intact but burned-to-a-crisp spinal column. 

It’s a matter of perspective. Everything you learn is valuable because somehow, sometime, you’ll draw upon it to save a life or prevent serious permanent injury.

Take care and stay safe.

Watch the UF PRO Combat Medic Essentials video series and learn more about the CUF phase, M.A.R.C.H. algorithm and different interventions from how to apply a tourniquet conversion or a peripheral IV. Learn more here.

About Tactical Combat Casualty Care (TCCC)

What is Tactical Combat Casualty Care?

Pre-hospital trauma care on the battlefield differs greatly than pre-hospital trauma care practiced in the private sector. The types and severity of injuries are different than those encountered in civilian settings and combat medical personnel face multiple additional challenges in caring for their wounded teammates in a tactical setting. They must provide care while under hostile fire, often working in the dark with multiple casualties and limited equipment. They must also often contend with prolonged evacuation times as well as the need for tactical maneuvering superimposed upon their efforts to render care.

Enter TCCC….

In the mid-1990s, a Special Operations medical research project was undertaken with the goal of improving the survivability of combat trauma injuries by improving the kind of care rendered on the battlefield. This research effort developed a new concept called Tactical Combat Casualty Care (TCCC) and proposed a set of pre-hospital trauma care guidelines that were customized for use on the battlefield. This effort was focused on the most common historical causes of preventable death in combat. The TCCC guidelines were quickly adopted by the Navy Sea, Air, and Land (SEAL) community, the 75th Ranger Regiment, and later by a few other military units. With increasing reports of success from units using the techniques advocated by TCCC, this new approach to battlefield trauma care began to spread throughout the US military. The tri-service Committee on TCCC (CoTCCC) was begun in 2001 to ensure that emerging technology and information is incorporated into the TCCC guidelines on an ongoing basis. The membership of the CoTCCC includes combat medics, Corpsmen, and PJs as well as physicians and physician assistants. The Committee is a standing multi-service committee charged with monitoring medical developments in regards to practice, technology, pharmacology and doctrine. New concepts in hemorrhage control, airway management, fluid resuscitation, analgesia, antibiotics and other lifesaving techniques are important steps in providing the best possible care for our Marines and Sailors in combat.

What is the primary intent of TCCC?

The primary intent of TCCC is to reduce preventable combat death through a means that allows a unit to complete its mission while providing the best possible care for casualties.

What are the principles of TCCC?

Tactical Combat Casualty Care (TCCC) is intended to treat potentially preventable causes of death on the battlefield, but acknowledges that application of these treatments may place the provider and even the mission in jeopardy if performed at the wrong time. Therefore, TCCC classifies the tactical situation with respect to health care provision into 3 phases (care under fire, tactical field care and tactical evacuation) and only permits certain interventions to be performed in specific phases based on the danger to the provider and casualty.

What are the phases of Care?

In TCCC prehospital battlefield care is divided into 3 phases:

• Care Under Fire (CUF) - CUF is characterized as the care rendered to a casualty while still under effective fire. In this case, the first action is to return fire and take cover as fire superiority over the enemy is the best medicine to include the casualty remaining engaged if able. As an enemy is suppressed, casualties can move or be move to more secure positions. The only medical treatment rendered in CUF if stop life-threatening hemorrhage (bleeding). TCCC actively endorses and recommends the early and immediate use of tourniquets to control massive external hemorrhage of limbs. All other treatment should be delayed until the casualty can be moved to a more secure and covered position and transitioned to tactical field care.
• Tactical Field Care (TFC) - TFC is care rendered by first responders or prehospital medical personnel (primarily medics) while still in the tactical environment. TFC is focused on assessment and management using the MARCH or DRSABCDE acronym. Massive hemorrhage is managed through the use of tourniquets, hemostatic dressings, junctional devices, and pressure dressings. The airway is managed by rapid and aggressive opening of the airway to include cricothyroidotomy for difficult airways. Respirations and breathing is managed by the assessment for tension pneumothorax and aggressive use of needle decompression devices to relieve tension and improve breathing. Circulation impairment is assessed and managed through the initiation of intravenous access followed up by administration of tranexamic acid (TXA) if indicated, and a fluid resuscitation challenge using the principles of hypotensive resuscitation. TCCC promotes the early and far forward use of blood and blood products if available over the use colloids and discourages the administration of crystalloids such as normal saline (sodium chloride). Hypothermia prevention is an early and critical intervention to keep a traumatized casualty warm regardless of the operational environment. Continued assessment and management in TFC includes treating penetrating eye trauma, assessing for traumatic brain injury or head injuries, treating burns, spling fractures, and dressing non-life-threatening wounds. TCCC promotes the early and aggressive use of analgesia (pain management) on the battlefield through the administration of Ketamine and/or Oral Tranmuccossal Fentanyl for casualties with moderate to severe pain. TCCC also promotes the early administration oral and intravenous or intramuscular antibiotics. The remainder of TFC care is dedicated is reassessment of injuries and interventions, documentation of care, communicating with tactical leadership and evacuation assets. TFC culminates with packaging a casualty for evacuation and then evacuating by available air, ground, or maritime assets.
• Tactical Evacuation Care (TACEVAC) - TACEVAC care encompasses the same assessment and management included in TFC with additional focus on advanced procedures that can be initiated when en route to a medical treatment facility. The caveat of TACEVAC is the evacuation means and care may or may not be dedicated medical platforms such as a MEDEVAC helicopter. TACEVAC can also include the evacuation of casualties on available non-medical assets and the provision of care in such circumstances.

How can I find out more?
To find out more, visit the website of the Committee of Tactical Combat Casualty Care -  www.cotccc.com