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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 1
CareUnderFire
ThefirstphaseofTCCCisCareUnderFire.
Objectives
DESCRIBEtheroleoffirepowersupremacyinthepreventionofcombattrauma.
DEMONSTRATEtechniquesthatcanbe
usedtoquicklymovecasualtiestocover
whiletheunitisengagedinafirefight.
EXPLAINtherationaleforearlyuseofa
tourniquettocontrollifethreatening
extremitybleedingduringCareUnderFire.
Readtext
Objectives
DEMONSTRATEtheappropriate
applicationoftheCATtothearmandleg.
EXPLAINwhyimmobilizationofthe
cervicalspineisnotacriticalneedin
combatcasualtieswithpenetratingtrauma
totheneck.
Readtext
NotethatCATreferstoaCombat
ApplicationTourniquet
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 2
CareUnderFireGuidelines
1.Returnfireandtakecover.
2.Directorexpectcasualtytoremain
engagedasacombatantifappropriate.
3.Directcasualtytomovetocoverand
applyselfaidifable.
4.Trytokeepthecasualtyfromsustaining
additionalwounds.
ReadtheCUFguidelines.
CareUnderFireGuidelines
5.Casualtiesshouldbeextricatedfrom
burningvehiclesorbuildingsandmovedto
relativesafety.Dowhatisnecessarytostoptheburningprocess.
6.Airwaymanagementisgenerallybest
deferreduntiltheTacticalFieldCarephase.
ReadtheCUFGuidelines
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 3
CareUnderFireGuidelines
7.Stoplifethreateningexternalhemorrhage
iftacticallyfeasible:
Directcasualtytocontrolhemorrhageby
selfaidifable.
UseaCoTCCCrecommendedtourniquet
forhemorrhagethatisanatomically
amenabletotourniquetapplication.
Applythetourniquetproximaltothe
bleedingsite,overtheuniform,tighten,
andmovethecasualtytocover.
ReadCUFGuidelines
CareUnderFire
Prosecutingthemissionandcaringforthe
casualtiesmaybeindirectconflict.
WhatsbestforthecasualtymayNOTbewhatsbestforthemission.
Whenthereisconflictwhichtakes
precedence?
Scenariodependent
Considerthefollowingexample:
Inthehospital,thecasualtyISthemission.InTCCC,youhavethecasualtyANDthe
mission.
CaseStudiesinSpecialOperationsWarfare
TheoryandPractice
Letsexamineascenariofromthisbookby
ADMMcRaven.Thescenariosinthisbookare
allSpecialOps,butthePRINCIPLESdiscussed
applytoallcombatunits.
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 4
RaidonEntebbe
byADMBillMcRaven
27June1976
AirFranceFlight139hijacked
FlowntoEntebbe(Uganda)
106hostagesheldinOldTerminalat
airport
7terroristsguardinghostages
100Ugandantroopsperimetersecurity
Israelicommandorescueplanned
Thisisoneofthemostfamoushostage
situationsinhistory.i
RaidonEntebbe
Rescue4July1976
ExitfromC130inaMercedesand2Land
RoverstomimicmodeoftravelofIdiAmin
theUgandandictatoratthetimeIsraelicommandosdressedasUgandan
soldiers
Droveuptotheterminalshotthe
Ugandansentry
Assaultedtheterminalthrough3doors
Thetacticsusedwereingenious:DECEPTION,SURPRISE,andVIOLENCE
Hereswhatthelayoutlookedlike.
BlackarrowsshowtheentrypathsoftheIsraeli
commandos.
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 5
RaidonEntebbe
LTCNetanyahuthegroundcommandershotinchestatthebeginningoftheassault
Whatshouldthecorpsmanormedicdo?
Disengagefromtheassault?
StartanIV?
Immediateneedledecompressionof
chest?
ImagineYOUarethecombatmediconthis
operation.
Whatwouldyoudonow?
(AskseveralpeopleintheaudiencewhatTHEY
woulddo.)
NotethatLTCNetanyahuwasthebrotherof
thefuturePrimeMinisterofIsrael.
Raidon
Entebbe
Aspreviouslyordered,thethreeassault
elementsdisregardedNetanyahuandstormedthebuilding.
Atthispointintheoperation,there
wasnttime
to
attend
to
the
wounded.
NOmedicalcareatthemoment.
Havetoestablishcontrolofthetactical
situationfirst.
Dosecondsreallymatterincombat?
LTCNetanyahudiedfromhiswounds.
Theassaultphaseoftheoperationtook90
seconds.
Didthe90secondtreatmentdelayaffecthis
chancesofsurvival?Probablynot.
Woulda90seconddelayincontinuingthe
assaultphaseoftheoperationhavemadeadifference?Absolutely.
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 6
MaalotRescueAttempt
byADMBillMcRaven
15May1974
3PLOterroriststake105hostages
Schoolchildrenandteachers
Whenassaultcommenced,terroristsbegan
killinghostages
22childrenkilled,56wounded
Thedifferencebetweenadramaticsuccess
andadisastermaybemeasuredinseconds.
Lookwhatevenamomentarydelaycanmean
toahostagerescueoperationOROTHER
TACTICALENGAGEMENTS.ii
CareUnderFire
Ifthefirefightisongoingdonttryto
treatyourcasualtyintheKillZone!
Suppressionofenemyfireandmoving
casualtiestocoverarethemajorconcerns.
Noteverycasualtyscenarioisahostagerescue,
butthesebasicprinciplesapply.
ImperativetogetyourcasualtyOfftheXand
behindcoverifyoucan.
CareUnderFire
Suppressionofhostilefirewillminimize
theriskofbothnewcasualtiesand
additionalinjuriestotheexistingcasualties.
Thefirepowercontributedbymedical
personnelandthecasualtiesthemselves
maybeessentialtotacticalfiresuperiority.
Thebestmedicineonthebattlefieldis
FireSuperiority.
Sustainingaminorwoundinafirefightdoes
notmeanthatyoushoulddisengagefromthe
fight.
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 7
MovingCasualtiesinCUF
Ifacasualtyisabletomovetocover,heshoulddosotoavoidexposingothersto
enemyfire.
Ifcasualtyisunabletomoveand
unresponsive,thecasualtyislikelybeyond
helpandmovinghimwhileunderfiremay
notbeworththerisk.
Ifacasualtyisresponsivebutcantmove,a
rescueplanshouldbedevisediftactically
feasible.
Nextsequenceofslidesshowsthehazards
ofmovingcasualtiesbeforehostilefireis
suppressed.
UnitmembersshouldbeTRAINEDtomove
themselvestopointoffirstcoverifable.
Dontputtwopeopleatriskifitcanbeavoided.
1)Whileunderfireandwithoutaweapon,GunnerySgt.RyanP.ShanerunstoSgt.
LonnieWells,topullhimtosafetyduring
USMCcombatoperationsinFallujah.
Hereisadramaticexampleofcasualty
movementduringCareUnderFire.SGTWellshadsustainedafatalgunshotthroughhisleg,
whichseveredhisfemoralartery.Fromthe
momenthewashit,hewasunabletoconduct
selfaidanddidnotrespondtocallsfromhis
fellowMarines.
2)GunnerySgtShaneattemptstopulla
fatallywoundedSgtWellstocover.
Readtext
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 8
3)AnotherMarinecomestohelp.ThethirdmanontheleftisHospitalCorpsman
JoelLambott,theplatoonsCorpsman.
4)Gunnery
Sgt.
Shane
(left)
is
hit
by
enemyfire.Readtext
5)GunnerySgtShane,ongroundatleft,
washitbyinsurgentsniperfire.
HMLambottwasstruckintheheeljustafter
GySgtShanewasinjured.Heprovidedlife
savingcaretoGySgtShane,directedhis
evacuation,anddressedhisowninjury.Hestayedwiththeplatoonandcontinuedhis
dutiesduringtheoperation.Inthisrescue
attempt,thefateofthefirstcasualtywas
unchangedandtwoadditionalcasualtieswere
sustainedbecauseeffectiveenemyfirewasnot
suppressed.
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 9
CasualtyMovement
RescuePlan
Ifyoumustmoveacasualtyunderfire,considerthefollowing:
Locationofnearestcover
Howbesttomovehimtothecover
Therisktotherescuers
Weightofcasualtyandrescuer
Distancetobecovered
Usesuppression
fire
and
smoke
to
best
advantage!
Recovercasualtysweaponsifpossible
DONTFORGETCOVERINGFIRE!
Ifpossible,letthecasualtyknowwhatyou
plan.
Considerdirectingavailablevehiclesto
moveintoapositiontoprovidecover.
TypesofCarries
forCareUnderFire
One
person
drag
with/without
lineTwopersondragwith/withoutline
SEALTeamThreeCarry
HawesCarry
Readtext
OnePersonDrag
Advantages:Noequipmentrequired
Onlyonerescuerexposedtofire
Disadvantages:RelativelyslowNotoptimalbodypositionfor
draggingthecasualty
(HaveotherInstructorsorstudents
demonstrate)
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 10
TwoPersonDrag
Advantage:Getscasualtytocoverfasterthan
withonepersondrag
Disadvantage:Exposestworescuerstohostile
fireinsteadofone
(HaveotherInstructorsorstudents
demonstrate)
Video:TwoPersonDrag Clickonvideotoplay.
TwoPerson
DragUsingLines
Advantages:CanshootwhiledraggingFasterthandraggingwithoutlines
Fastermovementofthecasualtyto
cover
Disadvantage:Exposestworescuerstohostile
fireinsteadofone
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 11
SEALTeamThreeCarry(1)
Advantages:Maybeusefulinsituations
wheredragsdonotworkwell
Lesspainfulforcasualtythandragging
Disadvantages:Exposestworescuerstohostile
fire.
Maybeslowerthandragging
Maybedifficultinkitandwithunconscious
casualty.
SEALTeamThreeCarry(2)
Casualtysarmsaroundshouldersofbothrescuers
Casualtyusesarmstoholdontorescuersif
able
Rescuersholdcasualtysarmsaroundnecksif
casualtynotableto
Bothrescuersgrabcasualtyswebbelt
Liftandgo
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 12
HawesCarry
Technique:Rescuersquats;casualtysarms
aroundrescuersneck;rescuerliftswithlegs
Advantages:Onerescuer
Maybeusefulinsituationswhereadragis
notagoodoption
Worksmuchbetterthanoutdatedfiremans
carry
Disadvantages:Hardtoaccomplishwith
rescuerand/orcasualtyskitinplaceDifficultwhenrescuerissmallandcasualtyis
large
Oftenslowerthandragging
Highprofileforbothrescuerandcasualty
CarriesPractical
HowNOTtoDoIt.
ThisisagoodexampleofhowNOTtocarry
yourcasualty.
Forpracticalexercise:
Breakupintogroupsof6orlessstudentsper
instructor.
UseskillsheetsintheTCCCcurriculumthat
applytoeachpracticalexercise.
Practiceallofthecarriescovered.
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 13
BurnPreventioninCUF
RemovecasualtyfromburningvehiclesorstructuresASAPandmovetocover.
Stopburningwithanynonflammable
fluidsreadilyaccessible,bysmothering,or
byrollingontheground.
Ifflammableliquidslikepetroleumproducts
causeafireonthecasualtysclothingthatyou
cantputout,thenyoullhavetocutthe
burninggarmentsoff.
BurnPreventioninCUF
WearfireretardantNomexglovesand
uniform!
Flameresistantclothingcanprotectyoufrom
burninjuries.Yourunitneedstheseclothingitemsifyou
donthavethemalready.
TheNumberOne
MedicalPriorityinCUF
Earlycontrol
of
severe
hemorrhage
is
critical.
Extremityhemorrhageisthefrequent
causeofpreventablebattlefielddeaths.
Over2500deathsoccurredinVietnam
secondarytohemorrhagefromextremity
wounds.
Injurytoamajorvesselcanquicklyleadtoshockanddeath.
Onlylifethreateningbleedingwarrants
interventionduringCareUnderFire.
IfyoucanonlydoONEthingforthecasualty
stophimfrombleedingtodeath.
DonottreatminorbleedingduringCareUnder
Fire.
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 14
Question
Howlongdoesittaketobleedtodeathfromacompletefemoralarteryandvein
disruption?
Answer:
Casualtieswithsuchaninjurycanbleedto
deathinaslittleas3minutes
10%ofanimalsinlabstudiesdiedwithin3
minuteswithouthemorrhagecontrolmeasures.
FemoralArtery
Bleeding
ThisisFEMORALARTERTYbleedinginapig.
Itdoesnottakelongtodiefromthis.
CareUnderFire
Theneed
for
immediate
access
to
atourniquetinsuchsituationsmakesit
clearthatallpersonneloncombat
missionsshouldhaveaCoTCCC
recommendedtourniquetreadily
availableatastandardlocationontheir
battlegearandbetrainedinitsuse.
Casualtiesshouldbeabletoeasilyand
quickly
reach
their
own
tourniquet.
DONOTburyyourtourniquetatthebottomof
yourpack.
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 15
CareUnderFire
Whereatourniquetcanbeapplied,itisthe
firstchoiceforcontroloflifethreatening
hemorrhageinCareUnderFire.
Forgetaboutdirectpressure,pressure
dressings,andanythingelseifyouhavesevereextremitybleedingintheCareUnderFire
phase.
Godirectlytoatourniquet.
APreventableDeath
Didnothaveaneffectivetourniquetapplied
bledtodeathfromalegwound
ThemedicinthisArmyunitwaskilledinthe
battleinwhichthissoldierwaswounded.
Othersintheunitattemptedtocontrolthe
bleedingfromthissoldierswoundjustbelow
hisleftknee.
Theseimprovisedtourniquetswereineffective,
andthesoldierbledtodeath.
DONTLETTHISHAPPENTOYOURBUDDIES!
TourniquetApplication
Applywithoutdelayifindicated.Boththecasualtyandthemedicarein
gravedangerwhileatourniquetisbeing
appliedinthisphasedontuse
tourniquetsforwoundswithonlyminor
bleeding.
Thedecisionregardingtherelativeriskof
furtherinjuryversusthatofbleedingto
deathmustbemadebythepersonrenderingcare.
Readtext
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 16
TourniquetApplication
NonlifethreateningbleedingshouldbeignoreduntiltheTacticalFieldCarephase.
Applythetourniquetwithoutremovingthe
uniformmakesureitisclearlyproximal
tothebleedingsite.
Tightenuntilbleedingiscontrolled.
Mayneedasecondtourniquetappliedjust
abovethefirsttocontrolbleeding.
Dontputatourniquetdirectlyoverthekneeorelbow.
Dontputatourniquetdirectlyovera
holsteroracargopocketthatcontains
bulkyitems.
Herearesomekeypointsaboutapplyinga
tourniquet.
AnatomyofaCATTM
TheCombatApplicationTourniquetTM(CA
TTM)(PatentPending)isasmalland
lightweightonehandedtourniquetthatcan
completelyoccludearterialbloodflowinan
extremity.
TheCATTMusesaSelfAdheringBandanda
FrictionAdaptorBuckletofitawiderangeof
extremitiescombinedwithaonehandedwindlasssystem.Thewindlassusesafree
movinginternalbandtoprovidetrue
circumferentialpressuretoanextremity.The
windlassisthenlockedinplace;thisrequires
onlyonehand,withtheWindlassClipTM.TheC
ATTMalsohasaHookandLoopWindlass
StrapTMforfurthersecuringofthewindlass
duringpatienttransport.
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 18
CATOneHandedApplication
toan
Arm
Step4:Twisttheroduntilthebleedinghas
stopped.
CATOneHandedApplication
to
an
Arm
Step5:LocktherodinplaceintheWindlass
ClipTM.
CATOneHandedApplication
to
an
Arm
Hemorrhageisnowcontrolled.
CATOneHandedApplication
toanArm
Foraddedsecurity,andalwaysbefore
movingapatient,proceedtosecurethe
WindlassRodTMwiththeWindlassStrapTM.
Forsmallextremities,youwillalsosecurethe
SelfAdheringBandTMundertheWindlassStrapTM.
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 19
CATOneHandedApplication
toanArm
Step6:AdheretheSelfAdheringBand
OvertheRodandcontinuearoundthe
extremityasfarasitwillgo.
CATOneHandedApplication
toanArm
Step7:Securetherodandthebandwiththe
WindlassStrapTM.Graspthestrap,pullit
tight,andadhereittotheoppositehookon
theWindlassClipTM.
CATOneHandedApplication
to
an
Arm
Thecasualtyisnowreadyfortransport.
CATOneHandedApplication
toan
Arm
Clicktostartvideo.
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 20
CATTwoHandedApplication
toaLeg
Step1:RoutetheSelfAdheringBand
Aroundtheleg.Passthefreerunningendof
thebandthroughtheinsideslitofthe
frictionadaptorbuckle.
CATTwoHandedApplication
toaLeg
Step2:Passthebandthroughtheoutside
slitofthebuckle.
CATTwoHandedApplication
toaLeg
Step3:PulltheSelfAdheringBandtight
andsecurelyfastenthebandbackonitself.
CATTwoHandedApplication
toaLeg
Step4:Twisttheroduntilbrightred
bleedinghasstopped.
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 21
CATTwoHandedApplication
toaLeg
Step5:LocktherodinplaceintheWindlass
ClipTM.
CATTwoHandedApplication
toaLeg
Hemorrhageisnowcontrolled.
CATTwoHandedApplication
toaLeg
Step6:Securetherodwiththestrap.Grasp
theWindlassStrapTM,pullittight,and
adhereittotheoppositehookonthe
WindlassClipTM.
CATTwoHandedApplication
toaLeg
Thecasualtyisnowreadyfortransport
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 22
CA
T
Two
Handed
Application
toaLegClicktostartvideo.
OtherTourniquets
TheSOFTacticalTourniquet(SOFTT)
byTacticalMedicalSolutions,Inc.
TheSOFTTisalsorecommendedbyISRand
theCoTCCC.Itwasfoundtobe100%effective
instoppingarterialflowinarmsandlegsin
laboratorytesting.Anecdotalreportssaythe
SOFTTmaybemoreeffectivethantheCAT
inindividualswithlargelegs.Itisnotfieldedas
widelyastheCATatpresent,butfeedback
frommedicsregardingitsusehasbeengood.
(NOTE:InstructionalslidesfortheSOFTTmay
befoundattheendofthispresentation.)
OtherTourniquets
EmergencyandMilitaryTourniquet
(EMT)byDelfiMedicalInnovations,Inc.
TheEMTfromDelfiwasfoundtobeaseffective
astheCATintestingattheISR.Itwasfound
tobebetterthantheCATinreportsfrom
MilitaryTreatmentFacilitiesintheater.The
EMTisapneumaticdevice,however,andnot
wellsuitedforcarriagebycombatmedics
becauseonefragmentofshrapnelthroughit
willrenderituseless.
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 23
ImpactofTourniquetUse
KraghAnnalsofSurgery2009
IbnSinaHospital,Baghdad,2006
Tourniquetsaresavinglivesonthe
battlefield
Bettersurvivalwhentourniquetswere
applied
BEFOREcasualtieswentintoshock
31livessavedinthisstudybyapplying
tourniquetsprehospitalratherthanintheED
Estimated10002000livessavedinwar
todatebytourniquets(dataprovided
toArmySurgeonGeneral)
MostimportantapplytourniquetsASAPwhen
theyareneeded.
Survivalimprovedifshockprevented.
SafetyofTourniquetUse
KraghJournalofTrauma2008
CombatSupportHospitalinBaghdad
232patientswithtourniquetson309
limbs
CATwasbestfieldtourniquet
Noamputationscausedbytourniquetuse
Approximately3%transientnervepalsies
RememberatthestartoftheGWOT,wewere
stilllosingcasualtiestoextremityhemorrhage.Weredoingmuchbetternow.
Thisstudydocumented232LIVESSAVEDin
thisONEhospitalinaONEYEARperiod.
MINIMALcomplicationsfromtourniquetuse.
Examplesof
Extremity
Wounds
That
DoNOTNeedaTourniquet
UseatourniquetONLY
forseverebleeding!
Neitherwoundislifethreateningbleedingisminimal.
Atourniquetshouldnotbeusedonthesetwo
woundsorotherwoundslikethemwherethe
bleedingisnotsevere.
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 24
TourniquetMistakes
toAvoid!
Notusingonewhenyoushould
Usingatourniquetforminimalbleeding
Puttingitontooproximally
NottakingitoffwhenindicatedduringTFC
Takingitoffwhenthecasualtyisinshock
orhasonlyashorttransporttimetothe
hospital
Notmakingittightenoughthetourniquetshouldeliminatethedistalpulse
Notusingasecondtourniquetifneeded
Waitingtoolongtoputthetourniqueton
Periodicallylooseningthetourniquetto
allowbloodflowtotheinjuredextremity
Thesearecommonmistakesmadebyfirst
respondersapplyingtourniquets.
TourniquetPain
TourniquetsHURTwhenapplied
effectively
Doesnotnecessarilyindicateamistakein
application
Doesnotmeanyoushouldtakeitoff!
ManagepainperTCCCGuidelines
Itisexpectedthattourniquetapplicationwill
causesomepain,butitwillalsosaveyour
casualtyslife.
Questions?
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 25
TourniquetPractical
Forpracticals:
BreakupintosmallgroupsAbout6or7studentsperinstructor
UseskillsheetsintheTCCCcurriculumthatgo
witheachpractical
HemorrhageControl
Somewoundsarelocatedinplaceswherea
tourniquetcannotbeapplied,suchas:Neck
Axilla(armpit)
Groin
Theuseofahemostaticagent(e.g.,
CombatGauze)isgenerallynot
tacticallyfeasibleinCUFbecauseofthe
requirement
to
hold
direct
pressure
for
3minutes.
BUTthecasualtymaygettocoverandhold
directpressureoverhiswoundsaspartofself
aid.
AirwayWillCoverinTFC
Noimmediatemanagementoftheairway
isanticipatedwhileintheCareUnder
Firephase.
Donttaketimetoestablishanairway
whileunderfire.Deferairwaymanagementuntilyouhave
movedcasualtytocover.
Combatdeathsfromcompromisedairways
arerelativelyinfrequent.
IfcasualtyhasnoairwayintheCareUnder
Firephase,chancesforsurvivalareminimal.
WewilladdressairwayintheTacticalFieldCarephase.
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 26
CSpineStabilization
Penetrating
head
and
neck
injuries
do
notrequireCspinestabilization
Gunshotwounds(GSW),shrapnel
Inpenetratingtrauma,thespinalcordis
eitheralreadycompromisedorisin
relativelylessdangerthanwouldbethe
casewithblunttrauma.
InstudiesfromtheVietnamconflict,ofthose
casualtieswithpenetratingnecktrauma,only
1.4%wouldhavebenefitedfromCspinestabilization.
Cspinestabilizationtakes56minutesevenfor
experiencedmedicalproviders.
ThisistoomuchtimetospendintheCare
UnderFirePhaseonaninterventionthatisnot
proventobenecessary
CSpineStabilization
Blunttraumaisdifferent!
Neckorspineinjuriesduetofalls,fast
ropinginjuries,ormotorvehicle
accidentsmayrequireCspine
stabilization.
Applyonlyifthedangerofhostilefiredoes
notconstituteagreaterthreat.
DonotprovideCspinestabilizationifthe
dangerofhostilefireconstitutesagreater
threatinthejudgmentofthemedic.
Summaryof
Key
Points
Returnfireandtakecover!
Directorexpectcasualtytoremain
engagedasacombatantifappropriate.
Directcasualtytomovetocoverifable.
Trytokeepthecasualtyfromsustaining
additionalwounds.Getcasualtiesoutofburningvehiclesor
buildings.
Askquestionstocoverkeypoints
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 27
SummaryofKeyPoints
AirwaymanagementisgenerallybestdeferreduntiltheTacticalFieldCarephase.
Stoplifethreateningexternalhemorrhage
iftacticallyfeasible.
Useatourniquetforhemorrhagethatis
anatomicallyamenabletotourniquet
application.
Directcasualtytocontrolhemorrhageby
selfaidifable.
Askquestionstoemphasize
Questions?
ScenarioBasedPlanning
IfthebasicTCCCcombattrauma
managementplanforCareUnderFire
doesntworkforyourspecifictactical
situationthenitdoesntwork.
Scenariobasedplanningiscriticalfor
success.Incorporatelikelycasualtyscenariosinto
unitmissionplanning!
Thefollowingisoneexample.
TheTCCCguidelinesarenotarigidprotocol.
Nothingincombatis.
Thinkonyourfeet!
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INSTRUCTORGUIDEFORCAREUNDERFIRE110808 28
Convoy
IED
Scenario
Letstakeascenariocommonlyencounteredin
IraqandAfghanistan.ImprovisedExplosiveDevices(IEDs)areavery
commoncauseofinjuryinthesetwotheaters.
ConvoyIEDScenario
Yourelementisinafivevehicleconvoy
movingthroughasmallIraqivillage.CommanddetonatedIEDexplodesunder
secondvehicle.
Moderatesniperfire.
Restoftheconvoyissuppressingsniper
fire.
Readtextinactionsequence
ConvoyIEDScenario
Youareamedicinthedisabledvehicle.
Personnexttoyouhasbilateralmidthigh
amputations.
Heavyarterialbleedingfromtheleftstump.
Rightstumphasonlymildoozingofblood.
Readtextinactionsequence
ConvoyIEDScenario
Casualtyisconsciousandinmoderatepain.
Vehicleisnotonfireandisrightsideup.
Youareuninjuredandabletoassist.
Readtextinactionsequence
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ConvoyIEDScenario
First
decision:Returnfireortreatcasualty?
Treatimmediatethreattolife
Why?
Restofconvoyprovidingsuppressive
fire
TreatmentiseffectiveandQUICK
Firstaction?
Tourniquetonstumpwitharterialbleed
Readtextinactionsequence
Askindividualsinaudiencetoanswer
questions
ConvoyIEDScenario
Nextaction?
Tourniquetonsecondstump?
NotuntilTacticalFieldCarePhase
Notbleedingrightnow
Nextactions?
Dragcasualtyoutofvehicleandmovetobestcover
Returnfireifneeded
Communicateinfototeamleader
Readtextinactionsequence
Askindividualsinaudiencetoanswer
questions
Questions?ThisistheendofCareUnderFire.Thescenario
willbecontinuedinTacticalFieldCare.
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SOFTacticalTourniquet SomeunitsusetheSOFTacticalTourniquet.
Theseslideswilldemonstrateitsuse.
SOFTTOneHandedApplication
toanArm
Step1:Openthetourniquet,exposingthe
loopofwebbing.Grasptherunningendof
thewebbingnearthebuckle,andslidethe
tourniquetovertheinjuredextremity.
SOFTTOneHandedApplication
toanArm
Step2:Pullthewebbinguntilthetourniquet
istightaroundthelimb.
SOFTTOneHandedApplication
toanArm
Step3:Twistthewindlassuntilthebleeding
stops.
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SOFTTOneHandedApplication
toanArm
Step4:Tosecurethewindlass,latcheither
ofitsnotchedendsintooneofthetriangular
ringsonthetourniquetbase.
SOFTTOneHandedApplication
toanArm
Step5:Tightenthesafetyscrewtoprevent
accidentallooseningofthetourniquetwhile
movingthecasualty.Thecasualtyisnow
readyfortransport.
SOFTTTwoHandedApplication
toaLeg
Step1:Removethewebbingfromthe
buckle.
SOFTTTwoHandedApplication
toaLeg
Step2:Positionthetourniquetbaseonthe
injuredlimbabovethewound.Routethe
webbingaroundthelimb.
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SOFTTTwoHandedApplication
toaLeg
Step3:Routethewebbingthroughthe
buckleandpulluntilthetourniquetistight.
SOFTTTwoHandedApplication
toaLeg
Step4:Tightenthewindlassuntilthe
bleedingstops.
SOFTTTwoHandedApplication
toaLeg
Step5:Tosecurethewindlass,lockeitherof
itsnotchedendsintooneofthetriangular
ringsonthetourniquetbase.
SOFTTTwoHandedApplication
toaLeg
Step6:Tightenthesafetyscrewtoprevent
accidentallooseningofthetourniquetwhile
movingthecasualty.Thecasualtyisnow
readyfortransport.
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Ontheseconddayofthestandoff,aunitoftheGolaniBrigadestormedthebuilding.Duringthetakeover,thehostagetakers
killedthechildrenwithgrenadesandautomaticweapons.Ultimately,25hostages,including22children,werekilledand68
morewereinjured.