Chapter 1 - Tactical Combat Casualty Care

MSTC, FT LEWIS WAMSTC, FT LEWIS WA

Tactical Tactical Combat Combat

Casualty CareCasualty Care

Lesson OneLesson One

IntroductionIntroduction

Soldiers continue to die on today’s Soldiers continue to die on today’s battlefield just as they did during the battlefield just as they did during the Civil War. The standards of care Civil War. The standards of care applied to the battlefield have always applied to the battlefield have always been based on civilian care principles. been based on civilian care principles. These principles while appropriate for These principles while appropriate for the civilian community, often do not the civilian community, often do not apply to care on the battlefield.apply to care on the battlefield.

Tactical Combat Casualty Tactical Combat Casualty CareCare

►90% of all battlefield casualties that die, 90% of all battlefield casualties that die, expire before they reach definitive care.expire before they reach definitive care.

►Point of wounding care is the Point of wounding care is the responsibility of the responsibility of the individual soldier, individual soldier, his battle buddyhis battle buddy, the Combat Lifesaver, , the Combat Lifesaver, and the Combat Medic.and the Combat Medic.

►Remember in combat, functioning as a Remember in combat, functioning as a Combat Lifesaver is your Combat Lifesaver is your secondarysecondary mission.mission.


►90% of all battlefield casualties that die, 90% of all battlefield casualties that die, expire before they reach definitive care.expire before they reach definitive care.

►Point of wounding care is the Point of wounding care is the responsibility of the responsibility of the individual soldier, individual soldier, his battle buddyhis battle buddy, the Combat Lifesaver, , the Combat Lifesaver, and the Combat Medic.and the Combat Medic.

►Remember in combat, functioning as a Remember in combat, functioning as a Combat Lifesaver is your Combat Lifesaver is your secondarysecondary mission.mission.


►Causes of death on the battlefield:Causes of death on the battlefield: Penetrating head trauma 31%Penetrating head trauma 31% Uncorrectable torso trauma 25%Uncorrectable torso trauma 25% Potentially correctable torso trauma 10%Potentially correctable torso trauma 10% *Exsanguination from extremity wounds *Exsanguination from extremity wounds

9%9% Mutilating blast trauma 7%Mutilating blast trauma 7% *Tension pneumothorax 5%*Tension pneumothorax 5% *Airway problems 1%*Airway problems 1%


►Causes of death on the battlefield:Causes of death on the battlefield: Penetrating head trauma 31%Penetrating head trauma 31% Uncorrectable torso trauma 25%Uncorrectable torso trauma 25% Potentially correctable torso trauma 10%Potentially correctable torso trauma 10% *Exsanguination from extremity wounds *Exsanguination from extremity wounds

9%9% Mutilating blast trauma 7%Mutilating blast trauma 7% *Tension pneumothorax 5%*Tension pneumothorax 5% *Airway problems 1%*Airway problems 1%


►Primary causes of preventable death Primary causes of preventable death

Hemorrhage from extremity woundsHemorrhage from extremity wounds

Tension pneumothoraxTension pneumothorax

Airway problemsAirway problems


► There needs to be a shift in our thinking, the days There needs to be a shift in our thinking, the days of not providing self aid and laying there and yelling of not providing self aid and laying there and yelling ““MedicMedic”” are over. We must have the ability to are over. We must have the ability to assess our own wounds, provide self or buddy aid if assess our own wounds, provide self or buddy aid if needed, and continue the mission if able. The needed, and continue the mission if able. The bottom line is a soldier capability at the point of bottom line is a soldier capability at the point of wounding, who is equipped and trained to decrease wounding, who is equipped and trained to decrease preventable battlefield death. This strategy will preventable battlefield death. This strategy will increase the unit’s combat effectiveness and it’s increase the unit’s combat effectiveness and it’s survivability. If we could make some minor changes survivability. If we could make some minor changes in our common soldier medical skills training, we in our common soldier medical skills training, we can improve the survival rate of can improve the survival rate of 15%15% of all of all battlefield deaths. battlefield deaths.

TC-3 ObjectivesTC-3 Objectives

►Treat the casualtyTreat the casualty

►Prevent additional Prevent additional casualtiescasualties

►Complete the missionComplete the mission


►Phases of CarePhases of Care

Care Under FireCare Under Fire

Tactical Field CareTactical Field Care

Combat Casualty Evacuation Combat Casualty Evacuation (CASEVAC) Care(CASEVAC) Care

CARE UNDER FIRECARE UNDER FIRE


► ““Care Under FireCare Under Fire” is the care rendered by ” is the care rendered by the soldier medic at the scene of the injury the soldier medic at the scene of the injury while they and the casualty are still under while they and the casualty are still under effective hostile fireeffective hostile fire..

► Self aid/ Buddy aidSelf aid/ Buddy aid Rapid Casualty AssessmentRapid Casualty Assessment Control HemorrhageControl Hemorrhage Treat Penetrating chest traumaTreat Penetrating chest trauma Maintain airwayMaintain airway Package casualty for transportPackage casualty for transport


►M.A.R.C.H.M.A.R.C.H. acronym acronym MM-massive bleeding-massive bleeding AA-airway-airway RR-respirations-respirations CC-circulation-circulation HH-head injury-head injury

HEMORRHAGE CONTROL IS TOP PRIORITYHEMORRHAGE CONTROL IS TOP PRIORITY


► Return fire as directed or requiredReturn fire as directed or required►Medical personnel’s firepower may be Medical personnel’s firepower may be

essential in obtaining tactical fire superiorityessential in obtaining tactical fire superiority►Move the casualty to cover as quickly as Move the casualty to cover as quickly as

possiblepossible►Direct the casualty to return fire, move to Direct the casualty to return fire, move to

cover, and conduct self-aid if ablecover, and conduct self-aid if able► Stop any life threatening external Stop any life threatening external

hemorrhage with a tourniquet or Emergency hemorrhage with a tourniquet or Emergency Trauma Dressing.Trauma Dressing.


► Try to keep yourself from being woundedTry to keep yourself from being wounded► Try to keep the casualty from sustaining Try to keep the casualty from sustaining

addition woundsaddition wounds► Suppression of hostile fire may minimize the Suppression of hostile fire may minimize the

risk of injury to personnel and minimize risk of injury to personnel and minimize additional injury to previously injured additional injury to previously injured soldierssoldiers

►Have casualty “play dead”Have casualty “play dead”►No immediate management of airway. No immediate management of airway.

Airway management is generally best Airway management is generally best deferred until the Tactical Field Care deferred until the Tactical Field Care

► Reassure the casualtyReassure the casualty


►Do not attempt to salvage a casualty’s Do not attempt to salvage a casualty’s rucksack, unless it contains items rucksack, unless it contains items critical to the missioncritical to the mission

►Take the patients weapon and Take the patients weapon and ammunition if possible to prevent the ammunition if possible to prevent the enemy from using it against you.enemy from using it against you.


►Exsanguination from extremity Exsanguination from extremity woundswounds is the is the #1#1 cause of preventable cause of preventable death on the battlefielddeath on the battlefield

► Injury to a major vessel can result in Injury to a major vessel can result in hypovolemic shock in a short time hypovolemic shock in a short time frameframe

►Use of temporary tourniquets to stop Use of temporary tourniquets to stop the bleeding is essential in these types the bleeding is essential in these types of casualtiesof casualties


The need for immediate access to a The need for immediate access to a tourniquet in such situations makes it tourniquet in such situations makes it clear that all soldiers on combat clear that all soldiers on combat missions have a suitable tourniquet missions have a suitable tourniquet readily available at a standard location readily available at a standard location on their battle gear and be trained in on their battle gear and be trained in its use.its use.

TACTICAL FIELD CARETACTICAL FIELD CARE


► ““Tactical Field CareTactical Field Care” is the care rendered by ” is the care rendered by the soldier medic once they and the casualty the soldier medic once they and the casualty are no longer under effective hostile fire. It are no longer under effective hostile fire. It also applies to situations in which an injury also applies to situations in which an injury has occurred, but there has been no hostile has occurred, but there has been no hostile firefire

► The Tactical Field Care phase is distinguished The Tactical Field Care phase is distinguished from the Care Under Fire phase by having from the Care Under Fire phase by having more time available to provide care and a more time available to provide care and a reduced level of hazard from hostile firereduced level of hazard from hostile fire





► In some cases, tactical field care may In some cases, tactical field care may consist of rapid treatment of wounds consist of rapid treatment of wounds with the expectation of a re-with the expectation of a re-engagement of hostile fire at any engagement of hostile fire at any moment. In some circumstances there moment. In some circumstances there may be ample time to render whatever may be ample time to render whatever care is available in the field. The time care is available in the field. The time to evacuation may be quite variable to evacuation may be quite variable from 30 minutes to several hours.from 30 minutes to several hours.


►Initial assessment consists of Initial assessment consists of AAirwayirway

BBreathingreathing

CCirculationirculation


► If a victim of a blast or penetrating If a victim of a blast or penetrating injury is found without a pulse, injury is found without a pulse, respirations, or other signs of life…respirations, or other signs of life…

DoDo NotNot attempt CPR attempt CPR

►Casualties with altered mental status Casualties with altered mental status should be disarmed immediately, both should be disarmed immediately, both weapons and grenadesweapons and grenades


►Traumatic chest wall defects Traumatic chest wall defects should be closed with an occlusive should be closed with an occlusive dressing without regard to venting dressing without regard to venting one side of the dressing or use an one side of the dressing or use an “Asherman Chest Seal“Asherman Chest Seal®®”. Place ”. Place the casualty in the sitting position the casualty in the sitting position if possible.if possible.


►Progressive respiratory distress Progressive respiratory distress secondary to a unilateral secondary to a unilateral penetrating chest trauma should penetrating chest trauma should be considered a tension be considered a tension pneumothorax and decompressed pneumothorax and decompressed with a 14 gauge needlewith a 14 gauge needle

►Tension pneumothoraxTension pneumothorax is the is the 22ndnd leading cause of preventable leading cause of preventable death on the battlefielddeath on the battlefield


►BleedingBleeding Significant bleeding should be controlled using a Significant bleeding should be controlled using a

tourniquet as described previously. tourniquet as described previously. Any bleeding site not previously controlled Any bleeding site not previously controlled

should now be addressed. Only the absolute should now be addressed. Only the absolute minimum of clothing should be removed.minimum of clothing should be removed.

Once the tactical situation permits, consideration Once the tactical situation permits, consideration should be given to loosening the tourniquet and should be given to loosening the tourniquet and using direct pressure or hemostatic bandages using direct pressure or hemostatic bandages (HemCon(HemCon®®) to control any additional ) to control any additional hemorrhage. hemorrhage.


►Tourniquet RemovalTourniquet Removal When? Based on the Tactical SituationWhen? Based on the Tactical Situation More time in a safer settingMore time in a safer setting More help availableMore help available Does the casualty need fluid Does the casualty need fluid

resuscitation?resuscitation? If so, do it before the tourniquet is If so, do it before the tourniquet is

removedremoved


► Tourniquet Removal (cont’d)Tourniquet Removal (cont’d) Take great precaution when loosening the Take great precaution when loosening the

tourniquet. Normally under medical supervision.tourniquet. Normally under medical supervision. DO NOTDO NOT periodically loosen the tourniquet to get periodically loosen the tourniquet to get

blood to the limb.blood to the limb. Can be rapidly fatal.Can be rapidly fatal. Tourniquets are very painful.Tourniquets are very painful. If the tourniquet has been on for > 6hrs, leave it If the tourniquet has been on for > 6hrs, leave it

on.on. If unable to control bleeding with other methods-If unable to control bleeding with other methods-

retighten the tourniquetretighten the tourniquet


► Initiate an IV via heplock or saline lockInitiate an IV via heplock or saline lock

► 1000ml of Ringers Lactate (2.4lbs) will 1000ml of Ringers Lactate (2.4lbs) will expand the intravascular volume by 250ml expand the intravascular volume by 250ml within 1 hourwithin 1 hour

► 500ml of 6% Hetastarch (trade name 500ml of 6% Hetastarch (trade name HextendHextend®®, weighs 1.3lbs) will expand the , weighs 1.3lbs) will expand the intravascular volume by 800ml within 1 hour, intravascular volume by 800ml within 1 hour, and will sustain this expansion for 8 hours and will sustain this expansion for 8 hours

► While in garrison, remove Hetastarch While in garrison, remove Hetastarch solution from CLS bagsolution from CLS bag


►Significant blood loss from any wound, Significant blood loss from any wound, and the soldier has no radial pulse or is and the soldier has no radial pulse or is not coherentnot coherent--STOPSTOP THETHE BLEEDINGBLEEDING-- by by whatever means available- tourniquet, whatever means available- tourniquet, direct pressure, hemostatic dressings, direct pressure, hemostatic dressings, or hemostatic powder etc. Start 500ml or hemostatic powder etc. Start 500ml of Hextendof Hextend®®. If mental status improves . If mental status improves and radial pulse returns, maintain saline and radial pulse returns, maintain saline lock and hold fluids lock and hold fluids


► If no response is seen give an additional If no response is seen give an additional 500ml of Hextend500ml of Hextend® ® and monitor vital signs. If and monitor vital signs. If no response is seen after 1000ml of no response is seen after 1000ml of HextendHextend®®, consider triaging supplies and , consider triaging supplies and attention to more salvageable casualtiesattention to more salvageable casualties

► Because of conservation of supplies, no Because of conservation of supplies, no casualty should receive more than 1000 casualty should receive more than 1000 ml of Hextendml of Hextend®®. Remember this is the . Remember this is the equivalent to six liters of Ringers equivalent to six liters of Ringers Lactate.Lactate.


►Splint fractures as circumstances Splint fractures as circumstances allow, insuring pulse, motor, and allow, insuring pulse, motor, and sensory checks before and after sensory checks before and after splintingsplinting


►Antibiotics should be considered in any Antibiotics should be considered in any wound sustained on the battlefield.wound sustained on the battlefield.

TACTICAL FIELD CARETACTICAL FIELD CARE►Combat Pill PackCombat Pill Pack

Tylenol 1000mg (Pain Medication)Tylenol 1000mg (Pain Medication) Mobic 15mg (Pain Medication)Mobic 15mg (Pain Medication) Gatifloxacin 400mg (Antibiotic)Gatifloxacin 400mg (Antibiotic)

CASualty EVACuationCASualty EVACuation

CASEVAC CareCASEVAC Care

► At some point in the operation, the casualty At some point in the operation, the casualty will be scheduled for evacuation. Time to will be scheduled for evacuation. Time to evacuation may be quite variable from evacuation may be quite variable from minutes to hours.minutes to hours.

► ““Combat Casualty Evacuation CareCombat Casualty Evacuation Care” is the ” is the care rendered once the casualty has been care rendered once the casualty has been picked up by an aircraft, vehicle or boat. picked up by an aircraft, vehicle or boat. Additional medical personnel and equipment Additional medical personnel and equipment may have been pre-staged and available at may have been pre-staged and available at this stage of casualty management.this stage of casualty management.


►Many of the same principles of care outlined Many of the same principles of care outlined in the Tactical Field Care phase will also apply in the Tactical Field Care phase will also apply to the CASEVAC phaseto the CASEVAC phase

► There are only minor differences in care when There are only minor differences in care when progressing from the Tactical Field Care progressing from the Tactical Field Care phase to the Casevac phase.phase to the Casevac phase. Additional medical personnel may accompany the Additional medical personnel may accompany the

evacuation asset and assist the medic on the evacuation asset and assist the medic on the ground. ground.

Additional medical equipment may be pre-staged Additional medical equipment may be pre-staged on the evacuating asseton the evacuating asset


►Priority is to move urgent casualties to Priority is to move urgent casualties to medical treatment facilities via fastest medical treatment facilities via fastest means available to youmeans available to you Tactical situation and resources available Tactical situation and resources available

are factors used to make this decision are factors used to make this decision



CASEVAC vs MEDEVAC: The CASEVAC vs MEDEVAC: The Battle of the Ia Drang ValleyBattle of the Ia Drang Valley

►1st Bn, 7th Cavalry in Vietnam1st Bn, 7th Cavalry in Vietnam►Surrounded by 2000 NVA - heavy Surrounded by 2000 NVA - heavy

casualtiescasualties►Called for MEDEVACCalled for MEDEVAC►Request refused because LZ not Request refused because LZ not

securesecure►Eventual pickup by 229th Assault Helo Eventual pickup by 229th Assault Helo

Squadron after long delaySquadron after long delay

CASEVAC vs MEDEVACCASEVAC vs MEDEVAC

►Use the term "Combat Casualty Use the term "Combat Casualty Evacuation" or “CASEVAC” to eliminate Evacuation" or “CASEVAC” to eliminate any misunderstanding of the mission any misunderstanding of the mission requiredrequired

►CASEVACCASEVAC Nonstandard vehicle, NO ENROUTE CARENonstandard vehicle, NO ENROUTE CARE May already be there or very close byMay already be there or very close by

►MEDEVACMEDEVAC Dedicated vehicle with en-route careDedicated vehicle with en-route care May take longerMay take longer

Evacuation Care in the Evacuation Care in the PastPast

►Medical care during CASEVAC expected Medical care during CASEVAC expected to be rendered by the medic present on to be rendered by the medic present on the mission phase of the operation.the mission phase of the operation.

►Why is this a problem?Why is this a problem? The medic may be among the casualties.The medic may be among the casualties. The medic may be dehydrated, The medic may be dehydrated,

hypothermic, or otherwise debilitated.hypothermic, or otherwise debilitated. There may be multiple casualties which There may be multiple casualties which

exceed the ability of the medic to care for exceed the ability of the medic to care for simultaneously.simultaneously.



RecommendationsRecommendations1.1. Base planning for combat casualties should be Base planning for combat casualties should be

incorporated into specific mission scenarios to aid in incorporated into specific mission scenarios to aid in identifying the unique medical and tactical identifying the unique medical and tactical requirements that will have to be addressed in that requirements that will have to be addressed in that scenario.scenario.

2.2. On combat missions, all soldiers should have a On combat missions, all soldiers should have a suitable tourniquet readily available at a standard suitable tourniquet readily available at a standard location on their battle gear.location on their battle gear.

3.3. All soldiers should be trained to use a tourniquet.All soldiers should be trained to use a tourniquet. 4.4. Designate and train Combat Casualty Transport TeamsDesignate and train Combat Casualty Transport Teams

SummarySummary

►Three most common combat injuries Three most common combat injuries on the battlefieldon the battlefield

►Soldiers who will do well regardless of Soldiers who will do well regardless of what we do for themwhat we do for them

►Soldiers who are going to die Soldiers who are going to die regardless of what we do for themregardless of what we do for them

►Soldiers who will die if we do not do Soldiers who will die if we do not do something for them Now (7-15%)something for them Now (7-15%)

SummarySummary

►If during the next war you could do If during the next war you could do only two things, (1) put a only two things, (1) put a tourniquet on and (2) relieve a tourniquet on and (2) relieve a tension pneumothorax then you tension pneumothorax then you can probably save between 70 and can probably save between 70 and 90 percent of all the preventable 90 percent of all the preventable deaths on the battlefield. deaths on the battlefield. COL COL Ron Bellamy 1993Ron Bellamy 1993

Questions????Questions????

Chapter 1 - Tactical Combat Casualty Care

Documents