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Rethinking Casualty Care in Tactical Situations, Part 1

Today we’re going to talk about something that nobody really likes to think about but that becomes very, very important the moment things go badly wrong. No matter how hard you train, no matter how high-quality and well-maintained your weapons and tactical gear are, there is always the possibility that you or a partner will take a round or otherwise be injured. I’ve been on the receiving end of having a buddy wounded by enemy fire, and believe me, it’s easy for your priorities to change abruptly when it happens. But this is not a situation in which you can just react—not if you want the best outcome for both the wounded officer and everyone else. Training—the right training—has to take over.

Not surprisingly, the military has the edge when it comes to treating casualties, since frequent and often extremely nasty injuries are an unavoidable consequence of combat. In the couple of decades after Vietnam, not much changed in the Army’s (as always, I’m going to address the Army’s way of doing things since that’s what I know) approach to casualty care. Attending Army basic training in the ’90s, I learned a curriculum that hadn’t changed much in a lot of years.

Now, all the medical advances that took place over the years weren’t ignored. The Army incorporated the best practices from emergency rooms and EMS into its medical care. The problem is that those advances came at the hospital level, which means in the rear away from the front lines where soldiers actually get injured. When my buddy was shot, we evacuated him by ground (it was quicker than waiting for a MEDEVAC bird) to the Troop Medical Clinic (TMC) where he was stabilized and then airlifted to the Combat Support Hospital (CSH) in the Green Zone. (We were deployed to Baghdad.) But it’s the time between injury and arrival at a medical treatment facility (MTF) that often determines survival—the so-called “golden hour.” Especially in a combat theater like Afghanistan, a MEDEVAC may well be more than a few minutes away, and arrival at an MTF even further.

It was the wars in Iraq and Afghanistan that, unfortunately, gave the Army lots of practical experience in the best way to treat casualties and save lives on the battlefield—what’s called tactical medicine. However, as it happens the first moves toward revamping what the Army now refers to as care under fire (CUF) came in the wake of the 1993 Battle of Mogadishu (dramatized in Black Hawk Down). The lessons learned in Iraq and Afghanistan helped to hone a new casualty care system that is now taught to all soldiers.

When I learned casualty care, the Army taught the venerable ABC (airway, breathing, circulation) model that you very well may have encountered in first aid training. The problem is that ABC comes from a non-combat trauma setting; I learned it as part of CPR in junior high school. The nature of injuries in a tactical environment (not to mention the nature of that environment itself) means that priorities need to be readjusted.

The first phase of what the Army calls Tactical Combat Casualty Care (TCCC) is care under fire (CUF). This is the part that the average soldier (or law enforcement officer) needs to know. I was fortunate that for our 2010 Iraq deployment, we had two excellent combat medics attached to my company who did an outstanding job of teaching these concepts.

The guiding principles of CUF boil down to two things: First, you aren’t going to do your buddy any good if you get shot or otherwise injured or killed trying to help him or her. That means the first priority must always be to eliminate or at least substantially reduce the threat before attempting any form of care. In other words, everyone must first focus on killing, driving off, or at the very least suppressing the enemy before anyone tries to reach the victim. This part of CUF is to me the hardest, because it goes against your basic human instincts. Yes, some guys have won the Medal of Honor over the years rescuing and/or treating the wounded under enemy fire. A lot of them died doing it, and most were at the minimum injured themselves in the process. I don’t discount the nobility of their actions, but the bottom line is that casualty care in combat is more akin to the scene early in Saving Private Ryan when Vin Diesel’s character Caparzo is wounded by a German sniper. No one moves from cover to help him until the sniper is located and killed, and consequently Caparzo dies, but all any of them would have accomplished would have been to get shot, too. It’s brutal, it sucks, but it’s reality. A balls-out charge into enemy fire to save your buddy looks great on film but isn’t likely to end well and frankly isn’t likely to save him, either.

Once the immediate threat has been nullified and care is possible, the CUF process can begin. The steps below come straight from current Army procedures:

  1.  Recognize that medical decisions are limited.
  2. Move to cover and return fire as necessary.
    1. Avoid being shot or otherwise injured.
    2. If able, the casualty should also return fire.
    3. Attempt to prevent the casualty from suffering additional wounds.
  3. The casualty should attempt self-care if able.
  4. Stop major, life-threatening bleeding.
    1. Bleeding in an extremity is treated with a tourniquet.
    2. Bleeding elsewhere is treated with a pressure dressing.
    3. Non-life-threatening bleeding is ignored.
  5. Airway management is ignored until the next treatment stage (tactical field care).
  6. Reassure the casualty.

The second stage of TCCC is tactical field care (TFC). This takes place only after the casualty has been moved to a safe location, and the first priority is to address any chest trauma such as a sucking chest wound. Care is typically provided by a medic if available or by a combat lifesaver (CLS), a soldier given additional first aid training, otherwise. The final stage is tactical evacuation care (TEC), which takes place as the victim is being moved to an MTF.

(Not that it’s vital to this discussion, but for your edification MEDEVAC (medical evacuation) is performed by medically-trained personnel capable of rendering care. CASEVAC (casualty evacuation) moves the casualty to an MTF with no option for treatment en route. To put this in a law enforcement context, loading a victim into an ambulance in the care of paramedics is MEDEVAC. Putting them in the back seat of your cruiser to rush them to the hospital is CASEVAC.)

In Part 2 of this discussion, I’ll look at the typical casualty care procedures employed by most law enforcement agencies, talk about training for procedures similar to the Army CUF model, and look at recommended first aid supplies that should be with you at all times.


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