Tactical Combat Casualty Care and Wound Treatment

CORRESPONDENCE COURSE OF

THE U.S. ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL

SUBCOURSE MD0554

TACTICAL COMBAT CASUALTY CARE AND WOUND TREATMENT

INTRODUCTION

When you have casualties on the battlefield, you must determine the sequence in which the casualties are to be treated and how to treat their injuries. This subcourse discusses the procedures for performing tactical combat casualty care; treating injuries to the extremities, chest, abdominal, and head; and controlling shock.

Subcourse Components

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This subcourse consists of eight lessons. The lessons are:

Lesson 1, Tactical Combat Casualty Care.

Lesson 2, Controlling Bleeding From an Extremity.

Lesson 3, Treating Chest Injuries.

Lesson 4, Treating Abdominal Injuries.

Lesson 5, Treating Head Injuries.

Lesson 6, Treating Burns.

Lesson 7, Treating Hypovolemic Shock.

Lesson 8, Treating Soft Tissue Injuries.

Here are some suggestions that may be helpful to you in completing this subcourse:

--Read and study each lesson carefully.

--Complete the subcourse lesson by lesson. After completing each lesson, work the exercises at the end of the lesson, marking your answers in this booklet.

--After completing each set of lesson exercises, compare your answers with those on the solution sheet that follows the exercises. If you have answered an exercise incorrectly, check the reference cited after the answer on the solution sheet to determine why your response was not the correct one.

Credit Awarded

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Upon successful completion of the examination for this subcourse, you will be awarded 16 credit hours.

To receive credit hours, you must be officially enrolled and complete an examination furnished by the Nonresident Instruction Section at Fort Sam Houston, Texas.

You can enroll by going to the web site http://atrrs.army.mil

and enrolling under Self Development (School Code 555).

A listing of correspondence courses and subcourses available through the Nonresident Instruction Section is found in Chapter 4 of DA Pamphlet 350-59, Army Correspondence Course Program Catalog. The DA PAM is available at the following website: http://www.usapa.army.mil/pdffiles/p350-59.pdf[URL inactive].

LESSON ASSIGNMENT

LESSON 1

TACTICAL COMBAT CASUALTY CARE

1-1.     GENERAL

As a combat medic on today’s battlefield, you will experience a wide variety of conditions not previously experienced. Your training has prepared you on standards that apply to the civilian emergency medical service (EMS) world that may not apply to the combat environment. These tools are a good basis for sound medical judgment; on today’s battlefield, this judgment could save the lives of your fellow soldiers. The US Army found the need to migrate away from the civilian standards and allow the combat medics to analyze situations in ways not previously thought of. These techniques are called tactical combat casualty care (TC3). These techniques and factors will be discussed in the following paragraphs. Factors influencing combat casualty care include the following.

a. Enemy Fire. It may prevent the treatment of casualties and may put you at risk in providing care under enemy fire.

b. Medical Equipment Limitations. You only have what you carried in with you in your medical aid bag.

c. A Widely Variable Evacuation Time. In the civilian community, evacuation can be under 25 minutes; but in combat, evacuation may be delayed for several hours.

d. Tactical Considerations. Sometimes the mission will take precedence over medical care.

e. Casualty Transportation. Transportation for evacuation may or may not be available. Air superiority must be achieved before any air evacuation assets will be deployed. Additionally, the tactical situation will dictate when or if casualty evacuation can occur. In addition, environmental factors may prevent evacuation assets from reaching your casualty.

1-2.     STAGES OF CARE

In making the transition from civilian emergency care to the tactical setting, it is useful in considering the management of casualties that occurs in a combat mission as being divided into three distinct phases.

a. Care Under Fire. Care under fire is the care rendered by the soldier medic at the scene of the injury while he and the casualty are still under effective hostile fire. Available medical equipment is limited to that carried by the individual soldier or the soldier medic in his medical aid bag.

b. Tactical Field Care. Tactical field care is the care rendered by the soldier medic once he and the casualty are no longer under effective hostile fire. It also applies to situations in which an injury has occurred, but there is no hostile fire. Available medical equipment is still limited to that being carried into the field by medical personnel. The time needed to evacuate the casualty to a medical treatment facility (MTF) may vary considerably.

c. Combat Casualty Evacuation Care. Combat casualty evacuation (CASEVAC) care is the care rendered once the casualty has been picked up by an aircraft, vehicle, or boat. Additional medical personnel and equipment may have been pre-staged and are available at this stage of casualty management.

1-3.     CARE UNDER FIRE

a. Medical personnel’s firepower may be essential in obtaining tactical fire superiority. Attention to suppression of hostile fire may minimize the risk of injury to personnel and minimize additional injury to previously injured soldiers. The best offense on the battlefield is tactical fire superiority. There is little time available to provide care while under enemy fire and it may be more important to suppress enemy fire than stopping to care for casualties. The tactical situation will dictate when and how much care you can provide. Finally, when a medical evacuation (MEDEVAC) is requested, the tactical situation may not safely allow the air asset to respond.

b. Personnel may need to assist in returning fire instead of stopping to care for casualties. This may include wounded soldiers that are still able to fight.

c. Wounded soldiers who are unable to fight and who are exposed to enemy fire should move as quickly as possible to any nearby cover. If no cover is available or the wounded soldier cannot move to cover, he should lie flat and motionless (play dead).

d. Figure 1-1 depicts a tragic situation. A wounded Marine is down in the street. A colleague attempts to come to his rescue along with a second Marine. Enemy fire continues in the area and the first rescuer is critically wounded. The second rescuer returns behind cover. Eventually, after enemy fire is contained, the first wounded Marine is rescued and the initial rescuer is permanently disabled. The point is, when under enemy fire, we cannot afford to rush blindly into a danger area to rescue a fallen comrade. If we do, there may be additional soldiers wounded or killed attempting to rescue our wounded.

Figure 1-1. Soldier and rescuers wounded.

e. Medical personnel are limited and, if they are injured, no other medical personnel will be available until the time of evacuation during the CASEVAC phase.

f. No immediate management of the airway is necessary at this time due to the limited time available while under enemy fire and during the movement of the casualty to cover. Airway problems typically play a minimal role in combat casualties. Wounding data from Viet Nam indicates airway problems were present in only about one percent of combat casualties, mostly from maxillofacial injuries.

g. The control of hemorrhage (major bleeding) is important since injury to a major vessel can result in hypovolemic shock in a short time frame. Extremity hemorrhage is the leading cause of preventable combat death.

NOTE

:   Over 2,500 deaths occurred in Viet Nam secondary to hemorrhage from extremity wounds; these casualties had no other injuries.

h. The use of temporary tourniquets to stop the bleeding

is essential in these types of casualties. If the casualty needs to be moved, as is usually the case, a tourniquet is the most reasonable initial choice to stop major bleeding. Ischemic damage to the limb is rare if the tourniquet is left in place for less than one hour (tourniquets are often left in place for several hours during surgical procedures). In addition, the use of a temporary tourniquet may allow the injured soldier to continue to fight. Both the casualty and the soldier medic are in grave danger while applying the tourniquet and non-life-threatening bleeding should be ignored until the tactical field care phase.

i. The need for immediate access to a tourniquet in such situations makes it clear that all soldiers on combat missions have a suitable tourniquet, such as the Combat Application Tourniquet (CAT) shown in figure 1-2, readily available at a standard location on their battle gear and that soldiers be trained in its use.

Figure 1-2. The Combat Application Tourniquet (CAT).

j. Penetrating neck injuries do not require cervical spine (C-spine) immobilization. Other neck injuries, such as falls over 15 feet, fast roping injuries, or motor vehicle collisions (MVC), may require C-spine immobilization unless

the danger of hostile fire constitutes a greater threat in the judgment of the soldier medic. Studies have shown that, with penetrating neck injuries being only 1.4 percent of the injured, few would have benefited from C-spine immobilization. Adjustable rigid cervical colors (C-collars) should be carried in the soldier medic’s medical aid bag. If rigid C-collars are not available, a SAM splint from the aid bag can be used as a field expedient C-collar.

k. Litters may not be available for movement of casualties.

(1) Consider alternate methods to move casualties, such as ponchos, pole-less litters, SKEDCO or Talon II litters, discarded doors, dragging, or manual carries).

(2) Smoke, CS (2-chlorobenzalmalononitrile, a type of riot control gas), and vehicles may act as screens to assist in casualty movement.

l. Do not attempt to salvage a casualty’s rucksack unless it contains items critical to the mission. Take the casualty’s weapon and ammunition, if possible, to prevent the enemy from using them against you.

m. Key points.

(1) Return fire as directed or required.

(2) The casualty should also return fire if able.

(3) Direct the casualty to cover and apply self-aid, if able.

(4) Try to keep the casualty from sustaining any additional wounds.

(5) Airway management is generally best deferred until the tactical field care phase.

(6) Stop any life-threatening hemorrhage with a tourniquet or a HemCon™ Bandage, if applicable.

1-4.     TACTICAL FIELD CARE

The tactical field care phase is distinguished from the care under fire phase by having more time available to provide care and a reduced level of hazard from hostile fire.

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

b. If a victim of a blast or penetrating injury is found without a pulse, respirations, or other signs of life, do not attempt cardiopulmonary resuscitation (CPR). Attempts to resuscitate trauma casualties in arrest have found to be futile even in the urban setting where the victim is in close proximity to a trauma center. On the battlefield, the cost of attempting CPR on casualties with what are inevitably fatal injuries will be measured in additional lives lost as care is withheld from casualties with less severe injuries and as soldier medics are exposed to additional hazard from hostile fire because of their attempts. Only in the case of non-traumatic disorders, such as hypothermia, near drowning, or electrocution, should CPR be considered. Casualties with an altered level of consciousness should be disarmed immediately. Remove