TACTICAL COMBAT CASUALTY CARE: A...

TACTICAL COMBAT

CASUALTY CARE:

A PROPOSAL

Lessons Learned for SoldiersLessons Learned for Soldiers

The Army LessonsLearned Centre

The Army LessonsLearned Centre

National Défense

Defence nationale

VOL 10 NO 2

November 2004

DirectorLCol CR Voss—4909

SO OperationsMaj M Boulé—5440

SO TrainingMaj N.P.M. Corriveau—4816

SO ReserveMaj SR Rankin—5117

SO CoordinationCapt IP McDonnell—4813

SO Research2Lt JM Davis—4813

Voss LCol CR@LFDTS [email protected]@forces.gc.ca

Boule Maj M@LFDTS [email protected]@forces.gc.ca

Corriveau Maj NPM@LFDTS [email protected]@forces.gc.ca

Rankin Maj SR1@LFDTS [email protected]@forces.gc.ca

McDonnell Capt IP@LFDTS [email protected]@forces.gc.ca

Davis 2Lt JM@LFDTS [email protected]@forces.gc.ca

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FOREWORD

My experience on Operation APOLLO placed me in the somewhat unique position of havingbeen an infantryman with more contact with trauma casualties than any of the medical staffdeployed, other than those employed within the UMS. The experience made me think aboutthe first aid skills taught to our soldiers and the situations in which they are expected to employthem. As a Paratrooper with emergency medical training, I had the advantage of a moreadvanced knowledge base and unique skill sets. I had already built upon these advantages priorto deployment, teaching my platoon some of the more advanced first aid techniques andattempting to keep those skills fresh in their minds.

The problems I ran into while trying to accomplish both tasks are the same as those addressedin this publication. Trying to employ civilian-based protocols in a tactical environment led tomany questions and issues. In discussions with medical personnel, I began amending a numberof the protocols to fit into the tactical environment. It wasn't until I re-deployed to Canada andbegan research in earnest into tactical medicine that I discovered American Navy Captain FrankButler's 1996 paper on Tactical Combat Casualty Care (TCCC). Since its publication, theguidelines noted within this document have been adopted by all U.S. military medicalcommunities, as well as in a number of other countries including Israel and the U.K., for casualtytreatment in a tactical combat environment. I admit to being confused as to why, outside of theJTF 2 (and the Patrol Pathfinder Course to a lesser degree), the CF has not adopted the doctrineadvocated by Butler.

When we began to create a trial TCCC course in April 2003 (with the approval and active supportof the Commander 1 CMBG, Col Beare), I was sceptical as to how far it would go. However, oncethe course began in July 2003 as a trial, the entire process took on a life of its own, withenthusiastic support coming from everyone involved, especially the operators who took thecourse. As the first course of its kind in the army, I believe it exceeded everyone's expectationsand opened a lot of eyes, including my own. As Capt King has stated, "it's not the 100% solution",but it's a huge start, with the caveat that this course has to be run "in the mud", so to speak, byexperienced personnel. What the future of the TCCC course is remains to be seen, but steps areunderway to implement it at the national level.

The process has not been without controversy. The debate encouraged by this publication beganlong before the Dispatches made it to print, all pointing to Tactical Medicine remaining acontroversial topic. There are legitimate worries that some people will read this paper andassume that, having read it, they are experienced enough to begin practicing tactical medicine.That is something we want to discourage. This publication is an attempt to convey that fact aswell as identify new approaches and equipment requirements.

It is by no means a 'how-to' manual nor a licence to practice the skills discussed herein.

People are often reluctant to change their opinions, particularly when you tell them that whatthey have been teaching is wrong or incomplete. After the completion of the trial course, Ibelieve that a number of those sceptics—medical and otherwise—were converted. We madebelievers out of them all. I believe that Tactical Medicine is a philosophy: a philosophy that hasthe potential to get lost in the future if Tactical Medicine is allowed to devolve back into the'Combat First Aid' category from which we are trying to rescue it. Those who become trainedand experienced in TCCC must continue to carry the torch and maintain the philosophy as thefuture unfolds, and TCCC takes shape within the CF.

Cpl Chris Kopp, 3 PPCLI

Editor's note: Cpl Kopp completed the civilian Paramedic course on his own and was one of the firstresponders on the scene following the 17 April 2002 friendly fire incident at the Kandahar firing rangein Afghanistan. Cpl Kopp has done a great deal of work in putting together both this document anda proposed training programme to meet the current Army deficiencies in tactical combat casualty care.

We at the ALLC are pleased to assist Cpl Kopp in continuing the carriage of that torch.

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Like Cpl Kopp, I had a truly unique and rewarding experience during my involvementwith 3 PPCLI on OP APOLLO. During pre-deployment preparations it becameapparent, while doing the medical estimate of our potential missions, thatsomething more than St. John's Ambulance First Aid would be required of oursoldiers if the Battle Group was to be properly medically supported. I had beenaware of Capt (N). Frank Butler's work for approximately a year prior to deploymentand began to look at it as a valuable approach in the Fall of 2001. As a medicalofficer, it quickly became obvious why so many of our allies have embraced thisapproach as an indispensable part of medical support to our combat arms troops.As I began to inquire why my branch has not adopted a similar Canadianized version,I was given a number of vague, unsatisfactory answers. So finally, in January 2002just prior to our deployment and after discussions within 3 PPCLI, the Battle Groupallowed me to give a three-hour lecture to company-sized groups regarding TCCC.The response from soldiers and the chain of command was overwhelming. Theyimmediately recognized the importance of the material and the tactical applicationsthat it contained. They, like me, could not believe this approach has been aroundsince 1996 and were struck with awe and dismay at the lack of forward thinkingwithin the medical branch. Since then, I have been continually impressed with theenthusiasm of the soldiers (like Cpl Kopp) for this material and their ability tounderstand and integrate it into their operations. The demonstrated success of thisapproach during deployment on many days, including April 17th, led to therecognition that our troops are ready and able to handle this material. In fact, theyare pleading for it. That is why Cpl Kopp and I, along with many others, are currentlyattempting to create a combined course for soldiers and medics based on Capt (N)Butler's work. I feel it is of the utmost importance that we come out of the 1950'sand into the 21st century if we are to give our soldiers what they deserve: the bestchance possible, should they come face to face with the ultimate sacrifice. To do anyless is to condemn some of our people to preventable deaths.

I am not advocating that every Canadian soldier be taught this approach; to doso would be far too resource intensive and unproductive.

However, based on my experience, I do believe there is a portion of the CF populationwho would benefit enormously from this material. The ideal target population canbe elucidated with further discussion between the medical branch and the operators.I do not pretend to have all the answers. The fact remains, this approach to combattrauma will save lives. I believe we owe our soldiers at least that. I hope you findthis publication thought provoking and useful.

Captain Roger KingMD, CCFP

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TABLE OF CONTENTS

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TACTICAL COMBAT CASUALTY CARE: A PROPOSAL

PART 1 BACKGROUND 4

PART 2 ENVIRONMENTAL DIFFERENCES— 6CIVILIAN PRE-HOSPITAL VERSUS COMBAT

PART 3 DEATH IN COMBAT 10

PART 4 COMBAT CASUALTY MANAGEMENT 15

PART 5 CONCLUSION 38

ANNEX A CASEVAC PRE-MISSION PLANNING 39

ANNEX B MASS CASUALTY EVENTS 41 AND TACTICAL TRIAGE

ANNEX C SCENARIO-BASED TRAINING 43

ANNEX D TRAINING CONSIDERATIONS FOR 47MEDICAL PERSONNEL

GLOSSARY OF ACRONYMS 49

REFERENCES / SUGGESTED READING LIST 50


PART 1—BACKGROUND

Tactical Combat Casualty Care (TCCC) is a concept of pre-hospital casualty managementspecific to the combat and tactical environments. It was developed in the mid 1990's inthe U.S. Special Forces community and has since evolved, earning a reputation ofeffectiveness across a broad spectrum of organizations. TCCC is being used by allAmerican military field medics, the British, Australian and Israeli armies, as well as withinour own JTF-2. Even civilian SWAT teams now employ tactical paramedics or TacticalEmergency Medical Support (TEMS) to provide medical coverage during police specialoperations using guidelines based on TCCC. Operations in Afghanistan forcefullyindicated the absolute requirement for doctrinal change within the Canadian Forces (CF)on how we treat casualties in tactical and combat environments.

The CF trains medical personnel to treat all trauma casualties in the pre-hospitalenvironment using protocols based on Basic Trauma Life Support (BTLS) andAdvanced Trauma Life Support (ATLS) (and, more recently, the Justice Institute ofBritish Columbia programs for pre-hospital emergency care). These protocols are theaccepted standard for civilian pre-hospital care in Canada and the U.S. (i.e. they weredesigned for paramedics who work out of the back of an ambulance in a civiliansetting). In a combat environment, however, it has become apparent thatmodifications to the guidelines are desperately required. Oxygen, spinalimmobilization, virtually unlimited resources, scene safety control and completeundressing of casualties are some examples of equipment and therapeutic measuresthat are taken for granted in civilian settings. Medics operating in combatenvironments are expected to modify their casualty treatment to the situation.Clearly though, the middle of a combat operation is the wrong place to beginthinking about how treatment protocols should be altered.

During their formal training, medics are taught minimal field craft and no tacticalskills. They are expected to learn those skills on the job upon posting to a field unit.Too often though, when training takes place, medics either find themselves providingmedical coverage to the exercise or employed within the unit medical station (UMS)where they are prevented from participating in the training exercise. In addition,junior medics have little or no real life trauma casualty management experience. Thisdiffers greatly from civilian trainings in which Emergency Medical Technician (EMT)and paramedic students are required to complete a certain number of actualambulance calls before receiving certification. These training deficiencies reduce thecombat effectiveness of the unit and add up to a weak link in the chain of survivalfor casualties incurred on operations.

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In every scenario, there is a larger mission that the Commander has to executeand I think that one of the primary responsibilities of anyone providing medicalcare is not to hinder the execution of the larger mission.

—Quote from then-Captain (USN) Eric Olson,former Chief of Staff of the Joint SpecialOperations Command, and a participant in the1993 Battle of Mogadishu

If you want to be a surgeon, follow an Army.

—Hippocrates


As well as better training for medics, there is a need for non-medic soldiers to be trainedto a higher level of casualty care than their current St. John's First Aid course. Annex Cidentifies some background on Scenario-based training that may help to develop casualtycare skills. During Operation APOLLO, situations involving ground force casualties clearlydemonstrated the need for higher level training. A number of possible situations illustratethe requirement that soldiers be trained to a higher level of casualty care:

Situations in which medics are not present. These often occur in operationswhere small units (platoon or smaller) are operating far from their supportbase or field headquarters (HQ's) without medical support readily available.

Mass casualty situations, which have the potential to overwhelm those medicspresent.

Lengthy wait times for Casualty Evacuation (CASEVAC) arrival.

Lengthy CASEVAC flights.

Clearly, while the St. John's First Aid course can be considered appropriate to the averagegarrison situation, it is not sufficient preparation for the soldier on the battlefield.

It does not adequately provide the soldier with the confidence and knowledgerequired to perform life saving care on combat casualties in a tactical environment.

Knowledge retention is often minimal because refresher training occurs onlyoccasionally, and because there is an inherent lack of reference in the training tothe combat environment (since it is a civilian course). The perceived irrelevancecan contribute to a distinct lack of interest from those taking the training.

The guidelines of St. John's First Aid have the same pitfalls as BTLS.

Finally, there is the perception among soldiers that combat casualty care willnever be needed as it is only rarely practiced during exercise.

If not the ATLS/BTLS protocol or St. John's style First Aid, what should Canadiansoldiers and medics use for treatment guidelines in such combat situations?

Relatively speaking, tactical medicine is a fairly new concept. To understand how tacticalmedicine should be provided, it is necessary to begin with a consideration of thedifferences between the combat treatment environment and the civilian treatmentenvironment. Once these differences are revealed, an analysis using statistical data canbe undertaken to determine how soldiers die in combat, and hence how these deathscan be prevented. This analysis will then form the basis for the development of aneffective management plan for combat casualty care in a tactical environment and newtraining standards in combat casualty care. These standards can then be war-gamed toreveal options or best practices on how to manage casualties within worst-case combatscenarios. The discussion that follows is based largely upon research published byCapt (N) Frank Butler. It largely because of Butler's research that the U.S military andother allies have already transitioned to the use of TCCC principles when dealing withtrauma casualties in the pre-hospital combat environments.

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The medical services is neither autonomous nor independent—it exists to servethe rest of the Army and must conform with, and be subordinate itself to, thegeneral plans of the Army.

—Extract from Australian MGen W.B. 'Digger' JamesAO MBE MC OStJ, author of Organization, Strategyand Tactics of the Army Medical Services in War


PART 2—ENVIRONMENTAL DIFFERENCES—CIVILIANPRE-HOSPITAL VERSUS COMBAT

Consider the following scenario:

A Platoon-sized element is tasked to provide security for a downed Coalitionaircraft. The pilot has already been recovered. The unit moves out, having a2 kilometre hike to reach the crash site within a rugged environment. Just asthe patrol reaches the crash site, an enemy ambush engages.

Injuries come fast and furious as the patrol assaults through the ambush. Theunit's signaller is hit, and is found with no pulse and no respiration. The unitCommander has massive trauma to one leg.

The standard BTLS approach to these injuries is as follows:

CPR (two personnel)

C-Spine immobilization, no spine board—improvise

Primary Survey—head to toe exam

Tourniquets discouraged

Definitive airway, (intubation probably impossible due to lack of skill by themedic)

Immediate transport (impossible)

2 large bore IV's for each casualty

IV fluid (normal saline or lactated ringers)

Continuous monitoring, blood pressure, electrocardiogram, etc.

Oxygen therapy

Cut off all the casualties clothes

Secondary Survey

Can these practices be effectively performed during combat?

What are the differences between a combat environment and a civilian casualtyenvironment?

Tactical environments require light and noise discipline.

Casualty assessment may have to be performed without the use of light, orpossibly with the use of night vision devices. Assessments may have to beperformed in the prone position. Communication with the casualty may belimited due to noise discipline requirements. A high noise environment, such asone filled with active helicopters, boats and vehicles, leads to hearing deprivationthat impacts a number of protocols pertinent to casualty assessment (theseinclude the auscultation of lung noises, checking blood pressure and pulsechecks). In addition, there is a high likelihood of sudden and unexpected vehiclemovement. All these factors combine to create unique casualty treatmentchallenges that cannot be avoided.

The priority of the mission may take precedence over the welfare of the casualty.

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Mission commanders may have to choose between mission success and casualtysurvival. While always a difficult decision, the importance of the mission maydictate such a decision. This clearly impacts on the relationship between theCommander and the medic. The patrol medic could be a member of the patroland an infantryman, if a medic was not present or available for the mission.Notwithstanding his relationship with the other members of the patrol, his firstpriority is to provide the Commander with an assessment of the casualty'scondition and to remind the Commander, based on his medical knowledge, of theconsequences of his mission-oriented decision.

Situations involving effective enemy fire, prolonged engagement, fluidtactical situation, compromised scene safety, and constant potential threatsdo not exist in civilian settings, but are likely and expected in a combatenvironment.

Extremely unsanitary, austere conditions are the norm during combat.

On operations, medical resources are often limited in availability.

Supplies are usually limited to what can be carried by the medic and any additionalsupplies that may be distributed among the unit. Medics cannot carry the heavyequipment that ambulance attendants take for granted. For example, oxygen, spineboards, cardiac monitors, and IV fluidsare heavy, large and cumbersome.Prolonged evacuation times ormultiple casualties will also taxmedical resources and can result veryquickly in critical shortages that arenot easily replenished. One otherpoint for consideration: in addition tomedical equipment, medics also carrytheir own personal kit, a taskCommanders often overlook.

Civilian evacuation times willusually range from 10 to 60 minutes,an objective which can usually bemaintained even in a rural setting.

On operations, the time forCASEVAC can range from one to72 hours and is dependant on thetactical and air situations.Depending on the threat levels,CASEVAC helicopters may alsorequire attack helicopter (AH)support, a requirement which can

An efficient medical service is a great conservator of manpower, as, by itsinsistence on the principles and practice of hygiene, it keeps the troops healthyand avoids wastage from sickness. It is a great incentive to good morale, asthey know that, if they are wounded, they will be well looked after.

—Australian Major General W.B. 'Digger' James,AO, MBE, MC, OStJ

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further complicate missions and increase planning and reaction times. Also, theactual distance to a care facility comparable with Canadian standards may besignificantly increased during operations. Occasionally, stops to refuel at forwardarea refuelling points (FARP) may be made before reaching field hospitals, therebyprolonging the evacuation and potentially endangering the CASEVAC resources.

Civilian trauma is predominately blunt trauma resulting from motor vehicleaccidents and falls. Combat trauma is predominantly penetrating, a result ofgun shot wounds, shrapnel injuries and blast wounds from explosives.

Casualties during operations will usually have a pre-injury stressor such asdehydration, sleep deprivation and mission stress and will often be in a veryunsanitary state.

Casualties will typically be young, healthy individuals with no medicalconditions.

So what does this mean? The bottom line is that to be effective, treatment in thetwo environments will differ greatly.

Certain protocols followed by civilian EMS systems can be contraindicated orimpossible due to the differences.

Extended CASEVAC times can and will drastically change casualty managementplans.

While comparisons between the civilian and combat environments are largelyobvious, there is a less obvious comparison that needs to be made between the two.Too often, our training is assumed to replicate those conditions we will encounterunder fire. This is a dangerous assumption from a casualty care point of view becauseon a field training exercise in Canada, all civilian resources and infrastructure isavailable. If a "no duff" casualty occurs during training, the exercise is halted toprovide the best possible care for the casualty. Therapeutic measures such as CPR,spinal immobilization, and supplemental oxygen therapy, taken for granted in civiliansettings, are also available for military exercises.

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Actual combat operations cannot be stopped for a casualty. Doctrine states that acombined unit will fight through the objective with medical care following upbehind to treat the wounded. Follow-on triage and further assessment will becompleted during the consolidation phase. This protocol assumes the fire fight iswon and there is a consolidation. This also assumes that the battlefield has definitearcs. We now operate in three dimensional, 360-degree battlefields. At times, thedifference between winning and losing the firefight can come down to having onemore rifleman engaging the enemy. That rifle is often the medic's, who is not in therear, but in the middle of the fight. It is important to realize that the medic mayonly be able to provide casualty care by first contributing effective fire to thebattle. Sometimes superior firepower is the best medicine!

Effective casualty management can be tactically compromising and can contribute tofurther casualties or possible mission failure. Casualty situations are thereforeboth a medical and tactical problem and should be considered in this light. Thedesired outcomes—sound care for the wounded and mission success—must beconsidered and balanced accordingto the tactical situation. Note thatthe ideal outcome will not always be possible. Commandersmust base their decisions on boththe tactical situation and thecasualty status reports from themedic. There may be times wherethe mission will take priority overthe welfare of the casualty.

The objectives of tactical casualtymanagement are (not necessarily inorder of priority):

Treatment of the casualty

Prevention of additionalcasualties

Completion of the mission

In addition to the differencesbetween the civilian and combatenvironments, the need to balancemission success with treatmentand prevention of furthercasualties, there are a number ofother factors in combat casualtycare not often considered,including:

Casualties may be encountered at any phase of the operation—duringinsertion, en route to the objective, on the objective or during extraction.Contingency plans must be made for all situations.

The sub-unit may be employed in circumstances where there is no medicreadily available, such as a recce detachment.

Medics can be easily overwhelmed by sheer number of casualties. The fact thatmedics could be the first casualties, given their often exposed and forwardlocation during operations, is rarely considered.

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PART 3—DEATH IN COMBATThe first task in examining combat mortality is to define those injuries that aretreatable on the modern battlefield.

It is important to understand that the individuals with the most severewounds are not necessarily the ones who should be treated first. Knowinghow soldiers die on the battlefield can provide information on how toprevent injuries, as well as a more realistic set of expectations for the careand outcome of injuries.

The following list provides a statistical breakdown of battlefield injuriesthat result in death:

31% are penetrating head injuries.

25% are surgically uncorrectable torso trauma.

10% are trauma that is potentially surgically correctable.

9% are exsanguinations from an extremity wound.

7% are mutilating blast trauma.

5% are tension pneumothorax.

1% are airway problems.

12% will die from infections and complications of shock.

Now look at these statistics regarding preventable deaths on the battlefield:

60% of preventable deaths are attributed to bleeding from an extremitywound.

33% are attributed to tension pneumothorax.

6% are attributed to airway obstruction and maxillofacial trauma.

So what do these statistics mean? Essentially, of all battlefield deaths:

Only 15% of battlefield casualties (the 9% identified above asstemming from exsanguinations from an extremity wound; the 5%attributed to tension pneumothorax; and the 1% from airwayproblems) can be treated effectively in the field.

An additional 10% have the potential for being managedsuccessfully if surgical intervention is made shortly after injury(which is reliant on a speedy CASEVAC).

Early antibiotic administration could potentially prevent about12% of deaths from infection, the third most common killer ofsoldiers. American units are now beginning to issue oral antibioticsto soldiers when they are issued bullets. If wounded, the soldierwould take his oral antibiotics as soon as possible.

The most common battlefield injuries that result in death areuntreatable. Untreatable injuries account for 63% of all combatcasualties.

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The following graphic illustrates the breakdown of battlefield injuries:

From these statistics, we can derive some important lessons:

The most common injuries that result in death involve penetrating headinjuries and torso trauma, the type of injury that personal protectiveequipment (PPE) is meant to protect against. This statistic demonstrates theimportance of PPE, but also shows that PPE is not 100% effective.Notwithstanding, the benefits of wearing PPE considerably outweigh the consas has been proven on a number of operational deployments, Op APOLLObeing one of the most recent example. Flak jackets with ballistic plates areheavy, cumbersome and hot, but are manageable and are responsible forsaving lives.

Bleeding to death from an extremity accounts for 60% of preventabledeaths, yet bleeding is potentially the easiest wound to treat. Application ofdirect pressure, haemostatic dressings, or application of an appropriatetourniquet, are three interventions that can easily be utilized in a fieldenvironment. Tourniquet application is a skill easily taught and can beperformed by any soldier, including the casualty himself.

The second most common cause of preventable death is a tensionpneumothorax. Although the skills needed to assess and treat this conditionare relatively simple, acquisition of these skills demands considerableanatomical knowledge and training. In addition to the substantial training,the potential for false diagnosis and complications means that it is unrealisticto provide such training to every soldier. Nonetheless, it is imperative that allfield medics be familiar with the signs and symptoms of tension pneumothoraxand that they have the skills needed to perform a needle thoracostomy.Training of key individuals in this technique for use in combat environments isa viable option that should be explored.

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The last preventable cause ofdeath is airway problems.The significantly lowpercentage of these cases, 1%of all battlefield deaths,contrasts sharply with theemphasis given airwayproblems in civilian guidelines.It is not the case that airwayproblems are unimportant, it ismerely that they are less likelyto occur on the battlefield.Simple procedures such asopening the airway, recoverypositioning and the use of basicadjuncts and hand suction areall viable remedies. However, inthe case of the complicatedairway, unless the medic istrained in combitube insertionor cricothyroidotomies and has the equipment available, a definitive airway may be impossible.

The next stage in examining combat mortality is to study the so-called CasualtyMortality Curve to determine what actions should be considered within specifictimelines in order to maximize life saving. The Mortality Curve identifies a timeframe forcasualty care, including the identification of considerations that should beacknowledged in terms of mortality statistics from combat. The table is by no meansan algorithm to follow blindly but, rather, is presented to show that time is not as criticalas one might assume. Hurrying blindly through assessment and treatment can actuallybe worse than taking the time to properly care for the casualty. Those soldiers who aregoing to die will probably die within the first few minutes and nothing can be done forthem. Only 10% will benefit from receiving treatment within the first hour. Theremaining casualties will live no matter what you do for them.

Preliminary data from American medical sources involved in OperationIRAQI FREEDOM provides compelling evidence of the success ofimprovements in tactical combat casualty care. While the use offorward surgical teams and the resulting speed of CASEVACs havedramatically improved casualty survival, innovations in medicaltechnology and an improved approach to casualty management astaught to both soldiers and medics have been deemed equallyresponsible. The result of improvements in the management ofbattlefield casualties, through both technology and improvingeducation and procedures is a drop in casualty rates from a modernhigh of 33% during World War II, to about 25% during the period upto and including Operation DESERT STORM, to an incredible andhistoric low of 12.5% during Operation IRAQI FREEDOM. Essentially,the Americans have reported a survival rate that has doubled betweenthe first and second Gulf region wars!

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Time Remarks

Firs

t fe

w m

inut

esConsiderations: Approximately 20% of combat injuries will result in an instantaneous death.These casualties will have suffered a major system trauma, usually involving the head and/orchest. This figure has remained relatively unchanged in the last 200 years, but the recent use ofPPE has reduced the percentage of instantaneous deaths from 25% to 20%. This figure includesthose cases in which casualties with injuries not compatible with life, survive for up to six minutesafter the traumatic event. Thus, after six minutes, about 80% of combat casualties will still bealive .

Action that will make a difference in survival:* Prevention of injuries* Use of PPE, including helmets, flak vests and ballistic plates* Good tactics* Proper training and rehearsals* Superior firepower

Firs

t fe

w m

inut

es t

o 1

hour

Considerations: After one hour without treatment, 10% of casualties will die fromexsanguinating hemorrhage, usually from the carotid or femoral arteries. During this period,other, less common causes of death include obstruction of the airway, choking on facial tissueand/or swelling of the airway. If a casualty can survive the first hour, it is highly likely he survivethe second hour. In other words, even after an hour without treatment, about 70% of combatcasualties will still be alive. If immediate action is taken to rectify bleeding and airway issues(e.g. tourniquets and airway management), the casualty survival rate will increase. Civiliansystems call this period the 'golden hour', and base their transport protocols on this, with theobjective of getting all patients to definitive care in under an hour.

Action that will make a difference in survival:* Self and Buddy aid* TCCC trained soldiers* Stop exsanguinating hemorrhage with a tourniquet or haemostatic agent, or direct

pressure* Antibiotic prophylaxis* Decompress tension pneumothorax* Open occluded airways* Corrective surgery in 10%

1 to

6 h

ours

Considerations: After six hours without treatment, another 10% of casualties will die, mostas a result of breathing complications. Even casualties with sucking chest wounds have thepotential to survive for up to six hours with no treatment! By this time, some casualties will beshowing the signs of shock caused by subtle bleeding, but they are unlikely to die from shockalone. Thus, after six hours without treatment about 60% of casualties will be alive.

Action that will make a difference in survival:* ALS level interventions by an experienced competent 5A+ medic* Oxygen therapy* IV access and fluid resuscitation* Advanced airway management* Antibiotic prophylaxis

6 ho

urs

+

Considerations: Between six and 24 hours deaths occur mainly from shock. Nonetheless, veryfew combat casualty deaths occur during this period so the mortality curve remains relativelyunchanged. 60% of casualties will be alive 24 hours after being injured.

Action that will make a difference in survival:* Surgical intervention and repair are required to show any marked improvements in

survival rates* Blood product replacement

Abo

ut72

hour

s Considerations: Between 24 and 72 hours without treatment, death occurs mainly as aresult of infection or long-term complications of shock. Where casualties survive severeshock, death may result about 72 hours later from permanent organ damage such as liveror kidney failure caused by shock.

Aft

er72

hour

s Considerations: The survival rate drops to about 50%


CASE STUDY: OPERATION APOLLO AND MASS CASUALTIES

On 17 April 2002, near Kandahar Airfield at Tarnac Farm in Afghanistan, a500 pound laser-guided bomb was dropped on a 3 PPCLI BG Company whichwas conducting a night live fire range (company sized group of120 personnel). The medical assets at the range included three medics andone LSVW (wheeled) ambulance. CASEVAC assets were available fromKandahar Airbase, which was located about four kilometers from the rangesite. This was a single event fratricide incident.

The casualties that resulted from the attack were as follows:

Four members of the company were killed, all generally from mutilatingblast trauma.

Eight were wounded, including one life threatening hemorrhage from anextremity wound and one breathing problem. The remainder sufferedvarying levels of concussions, burns and shrapnel injuries.

Statistically, about one in ten of those soldiers on the ground and involved inthe range were killed or wounded. 33% of those injured were killedinstantaneously, including one soldier who survived for about five minutesafter sustaining fatal injuries.

Lessons:

The incident reinforces the current data on battlefield mortality.

After the instantaneous deaths, the mortality curve has the potential toremain unchanged with proper treatment and quick CASEVAC.

Potential differences with a similar casualty scenario during combat wererevealed:

White light was used.

Movement of casualties was not required prior to the arrival of theCASEVAC.

CASEVAC timings were very short.

Equipment was available (from the on-scene ambulance) that wouldprobably not have been available during combat (examples: oxygen,spine boards, stretchers, and blankets).

Medical assets on-site were strained and assistance was required fromsoldiers on the scene. This experience reinforces the need for soldiers to betrained to a higher level of casualty care. Of note, soldiers with varyingdegrees of medical training over and above basic first aid responded to thecasualties on their own initiative.

Medics had the potential to have become casualties during this incident,which in turn would have lessened the available medical assets.

* PPE minimized and prevented injuries, and saved lives.

* Tourniquets saved a life (1).

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PART 4—COMBAT CASUALTY MANAGEMENTThere are three phases to Combat Casualty Management:

Phase 1—Care Under Fire. The beach scene from the movie, Saving Private Ryan,was an outstanding example of Care under Fire. This phase involves the careprovided at the scene of the injury, while still under effective enemy fire and whilemovement is restricted. During this phase, casualty retrieval and treatment areimportant, but the risks and benefits of both must be weighed against thepossibility of incurring further casualties (including the caregiver) and anescalation of the problem. Also, every bayonet removed from the fight to treatwounded is removing vital firepower. Remember, in this phase, firepower is thebest medicine!

Phase 2—Tactical Field Care. This phase involves care provided when the unit isno longer under effective enemy fire, or in situations prior to making contact withthe enemy. Examples would include casualties suffered while being helo- or air-inserted, during the move to an objective, or after an engagement in a securerendez-vous. The distinction between care under fire and tactical field care canbe somewhat subjective at times.

Phase 3—CASEVAC Care. This involves care provided during the evacuation to aMedical Treatment Facility.

Phase 1—Care Under Fire

There are seven steps to Care Under Fire. These should be completed in sequentialorder:

Step 1—Casualty Stays Engaged as a Combatant if Appropriate.

The casualty should return fire as directed or as required. Casualties should movethemselves to a position of the closest cover or concealment and perform self-aidif able to do so. This prevents others from trying to get to them. Maintaineffective fire if at all possible.

Step 2—Return Fire.

The care provider should return fire as directed or as required. Firepower may bethe only effective medical treatment that can be employed. Remember, every rifleremoved from the battlefield for casualty care could be detrimental to theoutcome and result in more lives being lost.

Step 3—Protect Yourself.

Keep yourself from becoming a casualty. Yell at the casualty to move rather thanmoving him yourself and exposing yourself to fire. Do not forget your training becausecasualties have occurred. Employ proper fire and movement techniques and tactics.

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No survivors from 138 trauma patients with pre-hospital cardiac arrest inwhom resuscitation (CPR) was attempted. Authors recommended no CPR incardiac arrest due to trauma. It can be argued that on battlefield, the CPRprovider may get killed, the mission is delayed and the casualty stays dead.

—Source: Rosemurgy et al. J Trauma 1993


Step 4—Protect the Casualty.

Keep the casualty from sustaining additional injuries. Get the casualty undercover or at least concealment if able to safely do so. If the casualty is unable tomove to cover or return fire, he should remain still and quiet with the lowestprofile possible. Methods of retrieval should be practiced and discussed duringthe planning and rehearsal phase of the operation. Consider different scenarios(e.g. a 140 pound rescuer retrieving a 220 pound casualty) and methods,including the use of smoke, diversions, vehicle cover, air support, or even basicimprovised methods (e.g. a carabineer and cord). Develop mission specific specialoperations (SOPs). Every situation will be different and a variety of rescuemethods should be practiced with emphasis on flexibility and options. Coveringfire with one person recovering the casualty is probably the only generic solution.To send more personnel to retrieve a casualty adds to the numbers exposed to fire.Remember, in the end, the tactical situation may preclude a rescue: this is adecision that rests with the commander. Attempts to recover the dead should notbe made if there is any possibility of endangering the rescuer, or if transport ofthe body will slow progress and endanger the patrol.

Step 5—Stop any life threatening bleeding with a tourniquet.

The war in Viet Nam saw more than 2500 American casualties who bled todeath from a limb.

All were without any other injuries and, more importantly, allwere preventable .

Attempting to maintain directpressure on a wound in the middle ofa firefight, while experiencing combatstress reaction, while in the face ofmounting combat casualties, andwhile trying to maintain situationalawareness and suppress strongemotions will be difficult. Thesituation may not be conducive to theperformance of a skill soldiers aretypically not trained to perform. Forthe inexperienced first aider, it may bedifficult to apply direct pressureeffectively in such a setting. Atourniquet may prove to be moreeffective until the situation calmsenough that more experiencedpersonnel can re-evaluate the meansby which bleeding is being controlled.

The most important assessmentand treatment during this phaseis to recognize life-threateningbleeding and apply a tourniquet.

Exsanguination from an extremity isthe number one cause of preventabledeath on the battlefield.

Non-life threatening bleeding should be disregarded until the Tactical FieldCare phase.

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The casualty's tourniquet should be applied immediately to the injured limbfollowing standard tourniquet rules. Place as close to the bleeding site aspossible and if possible write on the casualty's forehead the time applied, usinghis blood if a pen is not readily available.

NOTE

Many adequate manufactured tourniquets exist. Unfortunately none arecurrently in the CF medical supply system. The pilot TCCC course trialled twodifferent types. Feedback from US soldiers in Iraq has been informative. Thegeneral consensus is that a ratchet or caliper buckle tourniquet systemwith a broad strap of 1½ to 2½ inches wide is the best.

During the Tactical Field Care phase, sufficiently skilled medical personnel mayrelease the tourniquet and reassess control measures.

You may release the tourniquet in the presence of a medic or TCCC trainedsoldier. Always seek the back up of personnel trained in the procedure ofreleasing the tourniquet. This is because significant complications can result ifa tourniquet is released incorrectly. If no backup is available, it is reasonableto release the tourniquet and assess the status of bleeding. If the bleeding hasabated, a pressure bandage or direct pressure may be all that is required. Ifthe bleeding is still significant and potentially life threatening, then thetourniquet should be reapplied; time on the forehead remains the same.

If CASEVAC is going to be delayed, the tourniquet may be released after oneor two hours for two reasons:

In order to attempt to allow circulation to the limb.

Because there may be a sufficient clot formed that a pressure dressing maysuffice to control the bleeding.

Thereafter, the tourniquet should be released every one to two hours for about15 minutes either until the casualty is evacuated or the bleeding has stopped. Forlife threatening bleeding to the torso where a tourniquet will not work, directpressure (or a haemostatic agent like "Quick Clot" or "HemCon") is the best choice.

The risk to releasing the tourniquet is that the blood flow may damage anyexisting clotting.

Ask the question "Where does it hurt?"

Why?

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Non-pneumatic tourniquet (NSN 6515-00-383-0565) ½ by 42 inches …provedineffective. The tourniquet tended to slip around the thigh or arm whileattempting to tighten the buckle. In the end, medical personnel resorted togreen sling and stick to tighten around pressure points to stem the flow ofarterial bleeding in the extremities.

—Extract from the Field Report by the MarineCorps Systems Command Liaison Team


It may help to identify the location of the injury and bleeding.

It provides vital information on the casualty's level of consciousness, airwayand breathing.

Airway and breathing are not of vital concern during this phase as itaccounts for only 6% of preventable deaths on the battlefield. The onlyinterventions that should be made in regards to airway and breathing are toposition the casualty in the recovery position and manage it with gravity, andthis is only done if tactically feasible. Further airway interventions may bemade in the Tactical Field Care phase.

Ask the casualty if he can return fire or if he can move to a position of cover.

Why?

Helps determine if the casualty remains operationally employable.

Helps the casualty realize his situation after the shock of the injury.

May indicate a need to disarm the casualty.

Casualties who have an altered state of consciousness from any cause shouldbe disarmed. The decision to disarm casualties must be individualized for eachcasualty and situation. Training in this aspect of tactical decision-making should beadded to combat medical training programs for both combat medical personneland small-unit leaders.

Step 6—Reassure the Casualty.

Step 7—Transport the Casualty.

Unconscious casualties shouldbe transported in a recoverytype position if possible. Thisposition allows for moreprotection to the airway thanthe supine position.

Improvised stretchers such asa poncho, or manufacturedsoft stretchers, are valuableresources that are compactand light, but their use ismanpower intensive and exhausting. Another transport option may be a Lito-splint, a foldable light cardboard stretcher, which when bent, provides some spinalimmobilization. This could potentially be useful on parachute operations, or onlong range small vehicle patrols etc.

A length of 1 inch tubular nylon with a carabineer called a Keller Sling is avaluable tool for casualty extrication and transport. Essentially, the sling caneither be wrapped around the casualty for dragging; or can be thrown to thecasualty and clipped on, while the rescuer remains under cover. It can also beused to allow carriage of a casualty (the usual method is to wrap the casualty'sfeet in the sling, while a second rescuer carries the torso). This use of the slingfor casualty transport is very effective in building evacuation, particularly whenencountering stairs. The lead rescuer, by wrapping the sling around and overhis shoulders, is able to maintain security while on the move. The sling canalso be clipped to a soft stretcher, allowing the rescuer to wrap it around his

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body and carry the weight of the casualty and stretcher on his shoulders whilekeeping his hands free, maintaining weapon control and security. Clearly, thereare difficulties in maintaining tactical discipline; noise becomes a factor whenmaking use of the Keller sling.

Rotating the personnel who carry the casualties is important. Mission commandersmust be aware of the fact that speed will be greatly decreased without rotation.

Personnel not involved in casualty transport must provide vigilant security tomake up for the loss of firepower. Flank and rear security are critical duringcasualty evacuation.

If possible, mission essential equipment should be stripped off the casualty's ruckand carried by other members of the team. No effort should be made to carrythe casualty's kit, other than his protective equipment and weapon, if possible.

Phase 2—Tactical Field Care

The tactical situation will determine the speed and level of care provided during thisphase of Combat Casualty Management. Elements to be considered include:whether pursuing forces are expected, the degree of security offered by the area towhich the casualty has been moved, and whether delayed CASEVAC is expected. Thetime available will dictate the length of casualty care.

There are two major differences between Tactical Field Care and standard civilian care:

The equipment available and whether it is favourable to the conditions.

The patient treatment approach. Patient treatment discussion in this articlewill remain at 5A medic level and will not include skills beyond their scope.

The following steps comprise a suggested approach to Tactical Field Care. Thetactical situation and casualty care provider ratio will dictate amendments. Thisapproach has 12 basic steps that should be followed sequentially:

Step 1—Control life-threatening bleeding if it has not yet been controlled.

The best method to control bleeding is direct pressure. Knowledge of anatomy isrequired to assess whether bleeding is venous or arterial and to determine where

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pressure should be applied. Broad direct pressure, especially over a field dressing,is NOT as effective as placing a finger or two in the precise location of the bleeding.

The aim in using dressings is not to soak up the blood with dressings: it is toSTOP the bleeding. Bleeding should be controlled before the wound is dressed,if time permits. Do not be fooled by the term "pressure dressing" as it only appliesminimal broad pressure and may restrict venous return in the extremity.

DO NOT place dressings over soaked-through dressings: this will NOTcontrol the bleeding. If dressings are becoming soaked, they should beremoved, the location of the bleeding should be determined and directpressure from a couple of fingers should be used to control the bleeding.

If any of the dressings are adhering to the wound (which they won't do if thebleeding is soaking through), then leave it in place so as not to disturb anyclotting which has occurred.

Indirect pressure may be useful in some circumstances. "Indirect pressure" ispressure applied to an artery at the location where it travels near a bone. Byapplying pressure, the blood flow is reduced or halted, allowing for the temporarycontrol of hemorrhage in those instances when direct pressure is not effective orpossible. The diagram below illustrates points for controlling bleeding throughindirect pressure points.

Pressure points for control of bleeding.Source: Integrated Publishing, online at www.tpub.com

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Direct pressure is not always possible in the tactical environment. Because ofthis, there are a number of alternatives being researched and trialled for use inthe field. These alternatives include haemostatic dressings, granular mineralsponges, and injectable solutions that promote clot formation. Thealternatives all have benefits and risks associated with their use, however,direct pressure should be used whenever possible.

The following information on haemostatic agents is presented to highlight oneof the emerging alternatives. Research and evaluation on these types of agentsis continuing and recommendations on how and when to use them are in theprocess of being developed and/or amended.

Consider a Haemostatic Agent:

An example is the granular form mineral sponge.

When applied to an open wound it rapidly absorbs plasma from bloodleaving red blood cells and platelets to clot almost instantly.

The agent will stop arterial bleeding if blood pressure has droppedfrom hemorrhage.

Use of a haemostatic agent is the only method of bleeding control that hasa 0% mortality rate in animal model studies. Animal studies involved asevered femoral artery and vein which was allowed to bleed for 5 minutes.

The sponge does not have the negative side effects of tourniquets.

Agents are in use by the U.S. Navy, Marines, and Army.

Side effects of the granular mineral sponge are limited to an exothermic reactioncausing superficial burns that may occur if the sponge is used improperly. The riskof this unlikely and minor side effect is worth taking in order to save a life.

As stated, Haemostatic Agents are still in their infancy and the conditions under whichthey are to be used are under study. During the recent Iraq conflict (2003), the USgained experience with one particular agent. Consider these preliminary observations:

2nd Tank Battalion Surgeon stated that, in his opinion, the use of ahaemostatic agent was ineffective on arterial bleeding. Battalion Corpsmenattempted to use an agent on four separate occasions:

A wounded Iraqi civilian was shot near the brachial artery. Despite beingapplied as per the instructions and having dried, the haemostatic agentbegan flaking off. Standard direct pressure proved more effective.

An Iraqi civilian was shot in the back leaving a punctured spine. Pressurefrom the bleeding sprayed the haemostatic agent away: the haemostaticagent "was everywhere but on the wound".

An Iraqi female civilian was shot in the femoral artery and suffered severearterial bleeding. The medics were unable to apply a haemostatic agenteffectively due to the pressure of the blood flow from the wound and thecivilian bled out.

A Marine was shot in the femoral artery and a haemostatic agent wasapplied to the wound. The pressure from the bleeding soon caused thehaemostatic agent to be pushed out of the wound. A tourniquet wasapplied instead, but the patient died.

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In the opinion of the Battalion Surgeon, a haemostatic agent may prove moreeffective if applied in a 'buddy system' (one man applies the agent to thewound while the second quickly applies the sterile gauze). However, in hisopinion, applying a haemostatic agent as directed was ineffective, and directpressure and tourniquets were used instead.

—Extract from the Field Report by the US MarineCorps Systems Command Liaison Team

So what exactly does this mean? Should we avoid the use ofhaemostatic agents?

As stated earlier, these agents are in their infancy. Revisions in how and whento use them is under study. The American experience illustrates that there is aneed for better training in the specifics of agent use and more information onwhen (ie. for what type of bleeding) they are effective. There have beennumerous stories of success with regards to the use of an agent called "QuickClot". There is as yet no perfect solution, but advances are being made andtechniques being improved.

Step 2—Assess Level Of Consciousness (LOC).

Disarm casualties as required. Casualties need to be disarmed if they have analtered mental status that hinders judgment. This could be the result of a headinjury, shock or hypoxia, narcotic administrations such as morphine or battlefieldstress. If the casualty cannot discern between friend and foe, or is situationallyunaware, not alert and oriented to person, place, time or event, his weaponshould be removed.

Step 3—Inspect and Secure Airway.

Any conscious casualty who is breathing adequately on his own requires nointerventions.

A jaw thrust should be the initialairway management interventionin the unconscious casualty.

An inspection of the airway isimportant to determine thepresence of any active bleedinginto the airway, loose teeth ortissue. If any obstruction ispresent, the airway should besuctioned if possible and thecasualty placed into the recoveryposition for active drainage.

In the case of active bleeding fromthe nasal cavity, the use of a devicesuch as a foley catheter may beconsidered. Inflating the balloon ofthe foley after placement in thenasal cavity can help tamponadebleeding. Such intervention is bestleft to appropriately trainedmedical personnel becausecomplications can occur. However,

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it is appropriate for TCCC trained soldiers to be aware of these interventions. It isappropriate for them to suggest that medical personnel have these types of devicesavailable and that the medical personnel be competant in their use.

Turkey basters or obstetrical bulb suction units make small and excellent fieldsuction units.

Cervical spine immobilization during airway intervention procedures shouldonly be attempted if blunt C-spine trauma is suspected and if the procedure istactically feasible. Immobilization is a secondary issue, however, and securinga patent airway is of primary importance. Penetrating trauma needs NOC-spine precautions taken.

For unconscious casualties or those suffering from respiratory distress, a patentairway must be secured.

Intubation and cricothyroidotomy are beyond the scope of most field medics.However, many Special Forces medics are trained to perform these procedures.Many medics within the CF could acquire these techniques with propertraining and maintenance of competency programs. We advocate theteaching of these types of enhanced skills in order to maximally support ourcombat arms soldiers on deployment. The goal of medic training should beacquisition of these types of skills.

Without the enhanced skills discussed above, in the field, trained personnel aregenerally left with two choices, use of oropharyngeal (OPA) or nasopharyngeal(NPA) airways. OPAs are the popular choice, yet they have drawbacks in thetactical setting. They are easily dislodged and their use requires that thecasualty has no gag reflex. OPA use requires continuous monitoring, as thecasualty may regain consciousness and/or potentially vomit. In the tacticalsetting, the use of an NPA is favoured because it bypasses the gag reflex andcan be inserted into a conscious casualty. Once in position, it is not easilydislodged. A contraindication of NPAs has been the presence of a basilar skullfracture. However, one study in the UK found that in trauma casualties withbasilar skull fractures and clenched jaws, the most effective and appropriateairway management was the NPA. The contraindication seems to have beenin response to single case of intracranial insertion of an nasogastric (NG) tube.NPAs can easily be suctioned with an obstetrical bulb suction or turkey baster.In addition, correct use of NPAs can reasonably be taught to all soldiers.

Laryngeal Mask Airways (LMAs) are a good choice for the unconscious casualty.They are considerably more effective than NPAs and OPAs. No visualization ofthe airway is required for insertion, and they are potentially less traumatic thanintubation or use of Combitubes. However, LMAs may leak, causing a slightrisk gastric fluid aspiration. Combitubes are an appropriate choice for acomplex airway, and, while they require the medic to be trained in their use,they are a more appropriate choice than intubation in the field. They do notrequire visualization of the airway for insertion, and they are equally effectivewhen placed in either the esophagus or the trachea.

Step 4—Assess Breathing.

For the casualty presenting signs of respiratory distress (fast or slow breathing,painful breathing or cyanosis (blue lips and fingernail beds)), a change in LOCor agitation, a determination of the problem and an attempt to rectify it mustbe made. The casualty's chest and back should be exposed to assess for anypenetrations. Look for any signs of trauma, including entrance and exitwounds, jugular vein distention, and accessory muscle use. The chest should

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be palpated for asymmetrical or paradoxical movement of the chest wall, aswell as for any tenderness, crepitus, instability and subcutaneous emphysema.Auscultation of lung sounds can be undertaken but should not be a priority ofassessment. Auscultation of the lungs, heart or bowels in the field will give themedic no valuable information that will affect trauma treatment plans. Itmay be considered a waste of time and is often not effective because ofnoisy environments.

Decompress tension pneumothorax. Tension pneumothorax is the build up ofair between the chest wall and the lung due to a traumatic penetration to thelung. It is the second leading cause of preventable battlefield deaths.Penetrating chest trauma and progressive respiratory distress is indicative of atension pneumothorax and does not require auscultation, percussion, jugularvein distention or tracheal shift diagnosis in the field. In the case of blunttrauma, respiratory distress and the loss of the radial pulse, especially oninspiration, are indicative of the requirement for needle decompression, asother potential causes of respiratory distress may be present but ruled out bythe loss of the radial pulse. Therefore, an appreciation of the mechanism ofinjury is ALWAYS important. Needle decompression should only be performedunder Medical Direction by those trained in the procedure.

Consider needle decompression/airway management during the CareUnder Fire Phase.

Depending on the length of the engagement, consider quickly addressinga potential tension pneumothorax or compromised airway during the CareUnder Fire Phase. During the Iraq war Marine firefights in Al Nasariyalasted up to 24 hours. This dictated the additional considerations ofneedle decompression and airway management during the Care UnderFire phase. Traditionally, airway management is deferred until the TacticalField Care phase. However, if the length of the engagement is going to beprolonged, consider quickly addressing a potential tension pneumothoraxor compromised airway.

If the care provider feels it will be a considerable length of time beforethe casualty receives care in the Tactical Field Care phase, quick needledecompression for a tension pneumothorax may be attempted ifthe tactical situation allows. Because complete evaluation of thecasualty during the Care Under Fire Phase is not possible, theindications for needle decompression during Care Under Fire ispenetrating chest trauma with associated respiratory distress.

Similarly, quick insertion of a nasal airway may be considered if thereis obvious airway obstruction and delay is considered detrimental tothe casualty. Obviously, this decision will have to be made consideringthe risk to the care provider in performing the intervention and thefactors previously discussed regarding the overriding importance of themission and superior firepower. There is no textbook answer here andthe care provider will have to make case-by-case decisions on the spot.

An open pneumothorax (sucking chest wound) can be treated withAsherman Chest Seals or three sided taped occlusive dressings. Thelatter,however, are rarely effective in unsanitary field conditions. Bubblescoming from the wound are a good sign, as bubbling indicates that thecasualty is still attempting to maintain breathing, and the air is escapingthe pleural space. However, this can be falsely reassuring as air may buildup between the thorax and the lung as the patient sucks air in through the

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hole. Contrary to some laybeliefs, air entering the chestcavity through the hole does notprovide oxygen required by thebody for perfusion. This isbecause the oxygen is in thechest cavity and not inside thelungs. Therefore, air enteringthe chest in this way is of nobenefit with respect to gasexchange. The development of atension pneumothorax ispossible after treating an openpneumothorax. Casualties mustbe monitored for potentialdevelopment. An alternativetreatment for an openpneumothorax would be to putan occlusive dressing over thehole and decompress the chestvia needle decompression asrequired. For those not trainedin this skill, opening the sealcreated by the dressing mayrelease the air and alleviate thetension pneumothorax. Becauseequal benefits and risks accompany both laying the casualty on theinjured and the uninjured side, the casualty should be positioned forcomfort.

A flail chest is where 3 or more ribs are broken in two or more places. Youmay see, or feel the 'flail' section moving in the opposite direction of therest of the chest during respiration. Flail chests should not be stabilizedwith a bulky dressing and tape. This procedure has been found todecrease movement of the chest and increase breathing effort, and thus,pain. Treatment should focus on positive pressure ventilatory assistanceand some stabilization with the hand, although this may be hard tomaintain. Another treatment tactic is to place the casualty in the recoveryposition on the side of the injury with padding under the flail. This allowsthe ground to stabilize the flail, does not compromise chest expansion,and allows an open airway. Be very suspicious of underlying injuries tovital organs. Pain control in these casualties is of the utmost importance.A flail chest is one of the few indications for the use of morphine in thefield in a casualty with respiratory distress. This treatmentrecommendation highlights the fact that the basis of the problem forthese casualties is that breathing is too painful and, as a result, respiratorycollapse can occur. These casualties are likely to deteriorate quicklybecause of injury to the lung and require an immediate CASEVAC ifpossible.

A massive hemothorax, which is a large amount of blood between the lungand chest wall, is generally unmanageable in the field, and again treatmentshould focus on assisting ventilations. An attempt may be made todecompress the chest as in a tension pneumothorax. This may release any airthat is present. Again, these casualties require an immediate CASEVAC. Lifethreatening amounts of blood can be lost inside the chest cavity.

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CASE STUDY FROM OP APOLLO

While treating a local civilian with a gunshot wound to the chest, AshermannChest Seals were placed on the entrance and exit wounds. When the casualtywas 'log' rolled onto the stretcher, blood spurted out of the chest seals.Notwithstanding that this may have temporarily cleared the chest of blood, itis also considered an indicator of damage to blood vessels within the chest andthe consequent collection of blood within the pleural space.

Inadequate respirations should be treated by supplementing ventilationwith a pocket mask or bag valve mask (BVM) if available. This will be timeconsuming and exhausting for the care giver. It should only be performedif tactically feasible. Intermittent ventilation supplementation is, however,better than none at all. Oxygen saturation can be monitored with smallportable monitors such as the Nonin 9500, an excellent tool that can beone indicator for the requirement of ventilation support. The pulse Oxalso provides a pulse reading and can be very helpful to a busy medic.Oxygen is not usually available or feasible in the field, so the only meansof maintaining oxygenation in the casualty with respiratory distress in thefield is to supplement his ventilations without hyperventilation. Althoughthe use of chemical oxygen generators is not practical in the tacticalenvironment, new technologies have produced wallet sized O2 generatorsthat collect atmospheric oxygen and convert it to 100% concentratedoxygen at about 1L per minute. With the new re-breather mask this canequate to a 100% oxygen delivery system. Such devices show incrediblepromise for the future.

Step 5—Control Bleeding.

Control any non life threatening bleeding.

Perform a wet check by quickly examining the whole body for blood soakingthrough the uniform.

Exposure of wounds isimportant. However, removalof clothing and cutting theclothing completely off shouldbe avoided.

Exposure of the wound isimportant but the casualty will require his uniform for protection from theenvironment, camouflage or ifhe should become a prisoner ofwar (PW).

Hypothermia must be avoidedin the trauma casualty,although the risk is oftenoverlooked. While treating acasualty in the field, care mustbe taken to minimize heat loss.This could be the differencebetween survival and death ina multi trauma casualty.

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Trauma casualties CANNOT tolerate heat loss.

At this time all bleeding should be managed by applying direct pressure and apressure dressing.

Special care must be taken to assess the casualty for internal bleeding. All thesigns of shock without external signs of major bleeding indicate internalbleeding. The chest, abdomen, pelvis, and thighs can all individually holdenough internal hemorrhage to cause life threatening shock without anyexternal signs. In addition, in the case of external torso hemorrhage, it shouldbe assumed that a significant amount of internal bleeding has also occurred.There is no definitive treatment for these casualties in the field except fastCASEVAC. They need surgical repair.

Step 6—Monitor Vital Signs.

Vital signs should now be assessed, noted and monitored for change as oftenas every 5 minutes, if possible, in the seriously injured casualty. Vitals shouldalso be reassessed after every intervention, such as fluid resuscitation, needledecompression and after moving the casualty.Vital sign changes in a healthy individual will be a good indicator ofdeterioration. However, vital signs are not perfect indicators. Physiologicalreserves and strong compensatory mechanisms in healthy individuals maydelay the change of vitals until severe shock. Recent studies have suggestedthat the most sensitive indicator of deterioration is a decrease in a casualty'slevel of consciousness as a result of decreased blood flow to the brain.

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VITAL SIGNSRespirations An exceptionally good indicator of physiological stress.

Rapid respirations while the casualty is at rest needs to beinvestigated for cause.

Pulse Should be checked for rate, rhythm, and quality. A rapidweak pulse is indicative of hemorrhagic shock.

Blood Pressure Specific pressures need not be taken in the field. However,the presence or absence of a pulse at certain pulse points isa good indicator for systolic pressures.

Radial Pulse at least 70 mmHg

Femoral Pulse at least 60 mmHg

Carotid Pulse at least 50 mmHg

These pulse pressures are estimates and vary depending on the source ofinformation.

A fairly reliable but general sign in the field is that once the casualty loses theirradial pulse, they will probably lose consciousness as well.

50mm Hg is just barely enough to adequately perfuse the brain and keepthecasualty alive, but not conscious.

Temperature should be noted if the casualty is hypothermic or hyperthermic (heatstress casualty).

Hypothermia is often overlooked in the trauma casualty, and is of great concern.Specific temperature with a thermometer need not be taken on casualties exceptcold or heat stress casualties.


The Glasgow Coma Scale (GCS) should now be measured by trained personnel.(This GCS table is presented for familiarization purposes only. TCCC trainedcombat arms soldiers are not expected to memorize its contents. However,familiarization will facilitate CASEVAC when discussing the situation withmedical personnel at the CASEVAC staging area):

Blunt head injuries on the battlefield are a complex management challenge.The GCS provides one means to estimate the potential for serious brain injuryin these casualties. However, there are a number of other importantmanagement principles that are appropriate to discuss here.

When blunt injury occurs to the head, there is often a primary internal injury

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GLASGOW COMA SCALE

Eye opening response Spontaneous 4

To Verbal Command 3

To Painful Stimulus 2

No response 1

Best Verbal Response Alert and Oriented 5

Confused 4

Inappropriate Words 3

Incomprehensible Words 2

None 1

Best Motor Response Obeys Commands 6

Localizes Pain 5

Withdraws from pain 4

Flexion from pain 3

Extension from pain 2

None 1

Total 3 to 15

8 or less is indicative of a severe head injury and the casualty requires evacuationand intubation.9 to 12 is considered moderate and may require airway management.13 to 15 may have a mild head injury and should be monitored for deterioration.

A declining GCS score indicates neurological deterioration.


to the brain and surroundingstructures. This can includefractures and bleeding betweenthe brain and the skull causingcompression of the brain tissue.This can lead to an increase in thepressure within the skull. When such pressure occurs,management in the field involves maintaining physiologicnormalcy in the casualty.Research has shown thatmaintaining normal bloodpressure, temperature, and bloodglucose levels decreases theoccurrence of secondary braininjury (i.e. an injury that resultsdue to the affects of the initialinjury on the brain). Therefore,when managing a head injuredpatient in the field, it is extremelyimportant to maintain his normalbody temperature, ensure he hasa normal blood pressure (byinserting an IV if the casualtycannot drink), and maintainingnormal blood glucose levels if possible (this will depend on the presence ofmedics, PA's, or MO's).

Step 7—Provide Fluid Therapy.

NOTE

The benefits of fluid replacement in the pre-hospital setting have yet tobe proven.

Studies have shown a wide range of results in measuring the benefit oftraumatic fluid resuscitation and are dependent on casualty conditions.However, fluid resuscitation should now occur. This can be accomplished viathe oral, intravenous, or intraosseous routes.

Oral fluid resuscitation is a viable and easy way to rehydrate a casualty as longas he is conscious enough to protect his airway. If the CASEVAC is going to bedelayed and the casualty is conscious, oral fluid resuscitation should beadministered. The casualty should drink on his own, and to avoid choking,should not have water poured into his mouth. Penetrating abdominal traumaneed not be a contraindication. In some cases, such as where IV access is notpossible, drinking water may be the only way to replace fluids in the casualty.A conscious casualty in shock will often be thirsty. In the past, and as dictatedin BTLS, the guideline has always been nothing by mouth (NPO). Given thecircumstances in a tactical situation with limited IV fluid and delayedevacuation, the casualty in hypovolemic shock will benefit more from receivingfluid than from having it withheld. In a field environment, any casualty whocan drink fluids safely should be allowed to do so. If feasible, electrolyteadditives such as Gastrolyte or Gatorade can be added to the water beforeconsumption in order to improve absorption and retention. Concerns aboutthe casualty's possible need for surgery are secondary, since the stomach andbladder are routinely emptied before surgery at the Medical Treatment Facility. Oral

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fluid replacement should not replace Intravenous (IV)/Intraosseous (IO) therapy incasualties who require it. Oral fluid replacement is for use when these therapies arenot required, available or as a supplement to them.

IV and IO routes of fluid resuscitation are procedures that should only be performedunder Medical Direction by personnel properly trained to do so. Not every casualtywill require an IV, especially if it is going to be a hindrance to casualty movementand operational effectiveness.

Controlled bleeding with no signs of shock does not require IV fluid.

If the casualty's bleeding cannot be controlled, such as abdominal or thoracichemorrhage where direct pressure is insufficient, no amount of fluid should beinfused unless there is a decrease in LOC. Oral fluids should be administeredif the casualty is conscious. If torso hemorrhage is controlled, internalbleeding still has to be assumed and IV therapy withheld until a decrease inmentation is noted.

In the case of a decreasing LOC in uncontrolled hemorrhage, fluid may be infusedto a systolic pressure of 50 to 70 mm Hg to try to maintain cerebral perfusionuntil surgical repair.

Saline locks can be inserted and secured for use if the casualty is expected torequire fluid in the future or for the administration of medications or antibiotics.Saline locks should be flushed with 10 cc of normal saline every two hours tokeep the IV open.

Casualties with hypovolemic shock, where bleeding is controlled, should receivefluid replacement. This should occur via the IV or IO route by personnel trainedto implement this therapy.

When starting an IV, puncture site sterilization is not an absolute requirement inthe field. The use of an 18-gauge catheter will suffice, as opposed to using thetwo large bore IV's taught in BTLS. There is a higher success rate with the smallerneedle and it causes less pain to the casualty. As there are no large amounts ofblood to be infused, the larger gauge needle is not required. Nonetheless, shoulda blood transfusion be required, a 20 gauge needle can be used. (Note that,sometimes, even finer gauges are used in neonates.)

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REASONS NOT TO START AN IV

Most casualties can be adequately resuscitated with oral fluid if they areable to protect their airway (i.e. are conscious enough not to choke on theoral fluid).

To minimize interference with combatants who can continue to participatein the engagement.

To conserve resuscitation fluids for casualties who will require them.

To attend to severe casualties, as starting an IV is time consuming.

To avoid delaying tactical movement. Delays to administer IV fluids couldeasily translate into more casualties.

QUESTIONABLE BENEFIT. Aggressive IV fluid resuscitation has increasedmortality in some field studies. Although these studies are not definitive,they highlight the fact that IV's are certainly not a definitively beneficialintervention in a trauma casualty. However, because none of these studiesinvolved the delayed evacuation/transport times (1-72 hrs) that we oftenencounter during deployed operations, it is not clear how prolongedtransport times would impact on the issue of IV fluid resuscitation and itsconsequent effect on mortality and morbidity.

IV fluids are hard to keep warm especially in winter environments andcan lower body temperatures in casualties that cannot tolerate the dropin temperature.

IV fluid therapy may result in additional injuries to the casualty.

Intraosseous (IO) needles are a viable alternative if an IV cannot beaccessed, and if the skill and equipment is available (there are a number ofcommercial products available). Fluid resuscitation via IO is administeredthrough the sternum or proximal tibia by inserting a needle into the marrow.It can be delivered almost as fast as IV and has a number of advantages overthe IV:

It is a more successful means to access the casualty's vasculature.

It can be started more effectively at night.

It can be more effectively employed in the case of a hypovolemic casualtywhere a sufficient vein cannot be accessed.

In the tactical setting, the U.S. forces' current IV fluid of choice is Hextend,which is a colloid. This differs from the CF standard of normal saline (NS) orLactated Ringers (LR) crystalloids. Hextend has been chosen by the Americansbecause while less than one-third (about 200ml of an original litre) of NS or LRremains in the vascular system one hour after being infused, 1600ml ofadditional fluid remains in the vascular system after only a litre of6% hetastarch is infused. This is because Hextend possesses volume expandingproperties: it pulls fluid from the interstitium (from between cells) into thevascular system. This effect lasts for at least eight hours!

This effect is particularly important for two reasons:

First, in regards to casualty evacuation times, the lasting effect is beneficial.In a civilian setting, where ambulance transport times average 15 minutes,longevity is a not an issue and cheaper crystalloids suffice. When there is a

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lengthy or undetermined evacuation time, or the potential exists forprolonged casualty field care, the choice is obvious.

Second, there is a major difference in the amount of IV fluid that a medichas to carry. It would take about 8L of LR, which weighs about18 pounds to achieve the same effect as 1L of hetastarch, whichweighs about 2 pounds. An amount of saline may be infused in additionto the hetastarch to try and prevent dehydration, but overall the weightdifference is considerable.

Clinical research is currently ongoing in the CF, in conjunction with our Britishand American allies, with respect to the use of a Hypertonic Saline and Dextran(HSD) solution. Recent research meetings have confirmed the current level ofexcitement regarding this resuscitation fluid. All of the armies involved in theresearch agree that HSD is a promising alternative agent. Approximately250 ml of HSD is equivalent to 500 ml of Hextend. The clinical trials areongoing. Once definitive research has proven the preliminary results, TCCCrecommendations will be amended.

An initial bolus of 500 ml 6% Hextend or 250 ml HSD should be infused into apatient with signs of hypovolemia and controlled bleeding. Blood pressure shouldnot be the factor used to evaluate the rate and amount of fluid, but rather a goodperipheral pulse and improved level of consciousness. If the casualty still showssigns of shock after ½ hour, a second bolus of the same volume should be infused.Volumes of these fluids should not exceed 1L of Hextend or 500 ml of HSD. Hespanor Pentaspan are acceptable alternatives to Hextend. The only major differencebetween the products is that Pentaspan is a slightly smaller molecule.

If controlled hemorrhage casualty shows is no marked improvement in conditionafter resuscitation attempts, internal hemorrhage must be assumed andresuscitation should then follow uncontrolled hemorrhage guidelines.

Normal saline, Lactated Ringers, Hextend, Pentaspan and HSD do not carry oxygen.The problem with fluid replacement in the field is that it replenishes fluid volume inthe vasculature, but, it does not replace the essential red blood cells andhemoglobin lost that are required to transport oxygen to the cells.

That said, fluid replacement remains the most important aspect ofcardiovascular support for a hypovolemic trauma casualty afterhemorrhage control.

The preponderance of otherwise healthy individuals within a tactical setting givesthese types of casualties a significant amount of physiological reserve. Otherwisehealthy soldiers can maintain essential bodily function with hemoglobin levels aslow as 30-40g/l. Normal hemoglobin levels are 120-170 g/l, though they do needfluid replacement. Only in the most severe trauma cases is the existence ofextremely low hemoglobin levels a problem (below 30). If substantial amounts ofblood are lost, anemia becomes a problem. In these circumstances, even if thebleeding is controlled, fluid replacement can have minimal effect on perfusion.

New developments in artificial oxygen carriers in the form of artificial hemoglobin(Hb) solutions and perfluorocarbon (PFC) emulsions are currently under research.The advantages of these solutions include:

Higher oxygen transport capability than natural blood,

No requirement for cross typing and matching,

Few side effects, and

No refrigeration requirements.

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The use of these solutions is currently being researched by the CF for usein the field, as they have the potential to be a beneficial fluid replacementproduct for extreme hypovolemia in combat trauma casualties. The futuremay even see freeze dried versions of these products that could becarried by soldiers, and dissolved in a solute and infused by the medicwhen required.

Step 8—Perform Body Survey.

Casualties with an isolatedextremity injury (60–75% ofbattlefield casualties) with noother complaints do not requirean in depth head to toe exam.

Unconscious, semi-conscious,multi trauma casualties, blunttrauma casualties and thosewhere the mechanism of injuryis unknown should receive ahead to toe exam.

At this time complete astandard head to toe bodysurvey to find any injuries thatmay have been missed.Assessment by exposing thebody is important, butclothing should not be cut offand should be replaced assoon as possible.

Reintroduction of bowels back into the abdomen if they are exposed is acontroversial new consideration. The rapid and painful deterioration of exposedbowel is an issue in the field where movement and delayed evacuation is expected.What may start out as a small knuckle protruding through the abdomen, can quicklyturn into a considerable mass of intestines after the casualty has been moving,breathing and coughing.

A moist dressing and saran wrap is the preferred method of treatment,however, reintroduction back into the abdomen and taping the opening shut,even with gun tape, may provide the best protection from necrosis (death ofthe exposed tissue) and will prevent and minimize further injury and exposureof more bowel. Infection is the biggest concern following reintroduction. Thisshould be treated by antibiotics. In most circumstances, if the bowel is ruptured andits contents have spilled, reintroduction should not be attempted.

Step 9—Inspect and dress all wounds.

Once bleeding is controlled and shock is being treated, an effort must be madeto prevent further injury and contamination.

Clean the wounds with saline if it is available. Clean water will suffice ifsaline is not available.

Be careful not to remove dressings that have clotted to the skin. Removing dressingsdirectly against the wound may cause the disruption of any formed clot.

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Dress all wounds.

At this time, if tourniquets have been applied during the Care UnderFire phase and it is tactically feasible, direct pressure may be appliedand the tourniquets released and bleeding re-assessed by trainedpersonnel. If a haemostatic agent such as Quick Clot or HemCon isavailable it should be considered if the bleeding is not controlled bydirect pressure. If it is not available, and adequate direct pressurecannot be maintained, the tourniquet should be reapplied andreleased every 1 to 2 hours to attempt to perfuse the extremity andto assess clotting.

Bleeding of the torso presents a problem in the absence of ahaemostatic agent or if bleeding is internal. Direct pressure is the onlyviable means of controlling bleeding of the chest or abdomen. Directpressure for internal bleeding should not be performed because it isimpossible to determine the source of the hemorrhage.

Step 10—Provide pain control.

Traditional pain assessment questions are generally not appropriate in acombat casualty situation. Onset times, provocation, quality,radiation, severity and length of time the casualty has been in painare usually known or not important. Pain assessment should be basedon injuries and casualty conditions.

Morphine sulfate should be administered to those who are conscious andrequire pain control without any contraindications. It should NOT begiven to casualties with altered LOC, any forms of shock, respiratorydistress, or suspected head injury. Casualties with battlefield traumaoften have one of the preceding medical problems. It should also not beadministered unless Narcan (naloxone)is available to counteract it in theevent of overdose or allergic reaction. With these restrictions, morphine

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use in the field should be the exception rather than the rule. Morphinemust be administered with care as it can quickly turn a somewhat stablecasualty into an unstable one. No one has ever died of pain. Morphineshould quiet the casualty who is a large amount of pain but will also alterhis senses. This is an important consideration if the casualty needs toremain alert and coherent for tactical reasons. Morphine should not bewithheld from casualties who require it. It should not be given ininadequate doses because of fear of overdose.

IV is the preferred method for administering morphine as it takes effectmore rapidly and IV dosage and rate of absorption is easier to calculatethan intramuscular dosage and absorption rate.

If the casualty is conscious, pain medications should be administeredorally. Rofecoxib 50mg a day or Tylenol (acetaminophen) 1000 mg every6 hours.

WARNING

Soldiers should not take aspirin while on operations as these can interferewith blood clotting causing faster hemorrhage rates. Acetaminophen isthe non-narcotic pain relief of choice for soldiers at risk of combat injury.Motrin and Voltarin are acceptable anti-inflammatory medications.

Other methods of pain control for field use are currently being researched.Evaluation of intranasal medications (medications that are sprayed intothe nasal passages) is one such initiative. Medications such as Ketamineare being explored as potentially useful in tactical casualties whendelivered via an intranasal delivery system. The advantages of Ketamineare that it does not cause respiratory depression. One concern is that itshould be avoided in patients with head trauma because of its potentialto cause hallucinations. As with all things medical, there are benefits andproblems with each treatment. Further research will suggest the role ofthis medication and delivery system.

Step 11—-Splint fractures.

Splint any fractures if it is practical to do so.

Check neurovascular function by assessing distal pulses, sensation andmotor function both before and after splinting.

Remedy any decrease in pulse after splinting by adjusting the splint.

Quick splints or Sam splints are ideal for upper extremity fractures.

Kendrick Traction Splints are ideal for leg fractures. They are small andlight and provide femoral or tibia/fibula traction, which reduces tissuedamage and pain, and should be applied whether the distal pulse ispresent or not as it should relieve some pain. However, these splints arecontraindicated if the pelvis is fractured.

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Step 12—Administer Antibiotics.

Antibiotics should be administeredliberally in the operational fieldenvironment. Combat trauma alwaysinvolves unsanitary conditions andwounds become infected very easily.Many antibiotic regimes exist.Specific types of antibiotics should berecommended by medical staff prior to the mission. Therecommendations will depend onavailability, cost, and effectiveness ofthe various regimes. Gatifloxacin400 mg a day is the current oralmedication used by U.S. soldiers onoperations, although it canpotentially cause interactions withMefloquin (anti-malaria drug). Oralantibiotics, taken one per 24 hrs, arethe newest tools, however, medicsshould still carry IV antibiotics forunconscious patients.

Phase 3—CASEVAC Care

Planning for this phase of care will ensure the best possible outcome. Annex A outlinessome considerations for CASEVAC Pre-Mission Planning.

It warrants mentioning that in civilian EMS systems, terms such as the "platinum tenminutes" and the "golden hour" are used to highlight the fact that quick evacuation todefinitive surgical care is the one of the most important determinants of survival followingan injury. CASEVAC should never be delayed to perform medical interventions that are notdefinitely beneficial. Interventions that should not delay CASEVAC include such thingsas IV placement, completing a full secondary survey, and dressing all wounds.Casualties should ideally be loaded and moved with C-Spine precautions if they havesuffered blunt trauma and are consequently at significant risk of spinal injury. It is notedthat sometimes, even with a concerning mechanism of injury, proper C-Spine precautionsmay not be possible because of the tactical situation. That is the nature of war and thatis why this approach to casualty care exists. We cannot expect the ideal when engagedwith an enemy. Some other points to consider regarding CASEVAC are discussed in thefollowing paragraphs.

Medical Evacuation (MEDEVAC) and CASEVAC are often considered interchangeableterms, but in fact there is a significant difference between the two that needs to beclarified. A MEDEVAC is a routine aero-medical transfer, but has no tactical capability,whereas a CASEVAC is the evacuation of a casualty from a tactical environment. Hence forcombat care, we are looking at CASEVAC.

Generally, on small unit isolated missions, all mission personnel will be extracted at thetime of a CASEVAC. This will be dependant on mission priorities, unit capabilities andcommander's decisions. On larger scale operations, the casualty will probably beevacuated alone. This phase describes the care given once the casualty is en route to amedical treatment facility. While it may still be in the tactical setting, CASEVAC care willusually take place via vehicle, boat or helicopter. This setting adds to the difficultly inproviding assessment and care. High noise and limited space for maneuver exist on most

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evacuation platforms. Except in rare circumstances, medics will be the only personnelproviding CASEVAC care. Although these conditions will be less severe than those of thetactical ground situation, CASEVACs do pose some challenges:

Darkness and light restrictions may still be a problem.

Cold may be an issue, especially to the hands.

The CASEVAC platform will be crowded and space restricted.

High sound levels will make it harder to hear.

There are certain circumstances where triage and casualty status may require adeviation from standard protocol. For example, if the CASEVAC came under fire duringflight and the pilot was injured, the priority would shift to keeping the aircraft in the air,and the pilot would receive primary care regardless of the other injuries on board theaircraft. These situations are unique and actually fall under Care Under Fire, even thoughthe aircraft is involved in a CASEVAC. This article will not cover the specifics of care duringthis phase because there is no real reason to deviate from standard protocol. It will,however, cover mission specific issues for casualty evacuation.

The Canadian Forces has no combat search and rescue (CSAR) capability. Whendeployed on operations we rely heavily on the assets of allies, as they have the only viableresources in combat situations. CSAR usually pertains to downed pilot recovery. CASEVACfor conventional forces can take the form of an evacuation helicopter if there is anadequate security force on the ground, but will usually require attack helicopter (AH)support, or at least door guns for fire support. Once again, this requires assets fromcoalition partners. Ground evacuation can be considered a viable option if the operationis mechanized, or within vehicle range of the operations base.

Regardless of the method of evacuation, it should include medical personnel andnecessary medical equipment. It should not rely on the patrol medic or their equipmentfor the following reasons:

The medic will likely have to remain in the field with the unit.

The medic may be overburdened by casualty numbers and require additionalmedical support.

The medic's supplies may be exhausted and require replenishment.

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The medic may be dehydrated, hypothermic, or fatigued.

The medic may be the casualty.

However, in certain circumstances, when CASEVAC teams are unavailable or the CASEVACis the extraction, the patrol medic may have to provide the CASEVAC care. In the samecircumstances where the medic is the casualty, the responsibility then falls on the mostmedically experienced member of the patrol to provide the CASEVAC care.

CASEVACs can carry heavier equipment such as oxygen and spine boards. Ideally thereshould be a dedicated CASEVAC team. They would be responsible for preparingequipment used during the CASEVAC phase, as well as be familiar with the loading,unloading and casualty management on the evacuation platform and attend allCASEVACs. This is an important consideration during the mission-planning phase.

PART 5—CONCLUSION

None of us wants to think about his own mortality. Nor do we want to plan forwounds and disease on operations. This is evident when we look at the lip servicewe often place on combat casualty management during our training exercises. Whenwe do look at casualty management, it is often to dust off basic plans that areunproven in combat and based either upon a quasi-civilian training environment oran environment characterized by that found on peace-keeping operations. Casualtymanagement plans are rarely practiced or are abbreviated to the point of being nextto useless.

Too often, we ask; if something is not broken, why fix it?

It is said a smart person will learn from his mistakes, but a wiser person will learnfrom the mistakes of others. Our U.S. counterparts have invested incredibleresources researching effective combat casualty management plans that are basedon operational experience. Yet to this day we are still reluctant to officially changeour approach to combat casualty management. We may not have found ourselvesin a situation such as the battle of Mogadishu, but who is to say we never will?

We have to lose the mentality of "it will never happen to us".

If we want to participate in operations in the 'new world', we must understand therealities we will face. Casualties are inevitable. Prior to embarking on operations inAfghanistan, the CO 3 PPCLI BG stated:

"I'm going into this wondering who's going to be the first casualty?"

Then, after experiencing the first serious and fatal Canadian casualties onOp APOLLO, he said:

"Now I'm wondering who's going to be next?"

We must ask ourselves: are we truly ready to deal with casualties in a tactical combatenvironment? Have we provided our soldiers with the greatest chance of survivalthat they deserve? Are you and your soldiers confident in your abilities to dealeffectively with casualties during combat? What about in the event of casualtiesoccurring in the absence of a medic? If you cannot answer yes to these questions,then clearly it is time to re-examine your combat casualty management plans.

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ANNEX A—CASEVAC PRE-MISSION PLANNINGDuties of the medic:

Perform duties as required to support the unit's mission.

Medically treat unit members as required within his scope of practice.

Advise commanders on all medical matters during the mission in the absenceof radio medical direction.

Provide basic medical training to unit members under Medical Direction (MO).

Carry appropriate medical equipment and be trained in its use.

Know the team (allergies, blood types, injuries, illnesses, pertinent history).

Be involved in intimate cross training, learn and be proficient in the skills ofthose whom they treat.

Ensure medical equipment maintenance and inventory.

Prepare area study to include prevalent diseases, evacuation net, and medicalequipment needed specific to the mission.

Prepare for mass casualty incidents.

Duties of all unit members:

Be trained in basic TCCC, including tourniquet application, insertion of NPAsand treatment of open chest wounds.

Carry the required equipment to self treat for life threatening haemorrhage.Every soldier should carry two field dressings and a tourniquet in a standardlocation and be trained in their use.

Wear personal protective equipment as ordered.

Have adequate training and participate in mission rehearsals.

At least two soldiers per section should be trained in needle chestdecompression.

Duties of the mission commander:

Ensure subordinates are adequately trained and periodically refreshed inbasic TCCC.

Identify keen individuals and have them trained to a higher level of TCCC.

Establish SOP's including casualty extraction techniques and mass casualtyincident plans.

Ensure tactical combat casualty scenarios are practiced.

Ensure subordinates are adequately trained and rehearsed on unit and missionspecific SOPs.

Ensure that all members wear PPE.

Ensure all members are carrying field dressings and tourniquet in astandard location.

Ensure medical equipment is distributed among the group.

Ensure CASEVAC teams are available and adequately prepared.

Complete CASEVAC coordination.

Ensure medical equipment is pre-positioned on the CASEVAC platform.

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CASEVAC Co-ordination Checklist:

What Unit assets are available? What Theater assets are available?

What are the frequencies, call signs, and report formats. Every patrol membermust have this information.

What is the Enemy Situation in regards to CASEVAC. Is CASEVAC possible?Does it require escorts? What assets are available?

What is capacity of the aircraft/vehicle?

What is the range of the aircraft/vehicle?

What is air/ground CASEVAC plan?

What are Air/ground travel times, including aircraft crank time and personnelnotice to move (NTM) times.

What Routes can be taken?

Helicopter landing zone (HLZ) markings by day and by night.

Preplanned HLZs.

Specific loading drills. Equipment familiarization, triage.

What are CASEVAC limitations: Altitude, weather, enemy, distance/fuel?

Where are FARPSs?

What specific equipment is required: Sky genie, jungle penetrator, stokeslitter, etc.?

Determine how casualties are marked, by priority. Usually NATO standard.

Preposition medical equipment on the extraction/CASEVAC platform.

Brief CASEVAC Team only on mission specifics pertinent to them ifOPSEC allows.

Individual Operator Training:

Basic TCCC Training

St. John's First Aid

Tourniquet application

Direct and indirect pressure

Jaw-thrust

NPA's

Recovery positioning

Treat sucking chest wound

Assess for shock

Direct pressure bleeding control

Wound dressing

Oral pain meds

Oral antibiotics

Splint fractures


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CasualtyPrioritization What is it? Examples

Priority 1—Immediate (Red)

Rapid intervention andtransport is required tosave life, limb oreyesight. This isreserved for casualtieswho have a good chanceof survival.

Upper airway obstruction Severe respiratory distress Life threatening bleeding Tension pneumothorax Hemothorax Flail chest Extensive 2nd or 3rd degree burns Untreated poisoning (chemical agent)and severe symptoms Heat stroke Decompensated shock Rapidly deteriorating level ofconsciousness Any other life threatening conditionthat is rapidly progressing

Priority 2—Delayed (Yellow)

Casualties whosetreatment can wait a fewhours

Compensated shock Fracture, dislocation, or injurycausing circulatory compromise Severe bleeding, controlled by atourniquet or other means Suspected compartment syndromePenetrating head, neck, chest, back,or abdominal injuries without airwayor breathing compromise ordecompensated shock Uncomplicated immobilized cervicalspine injuries Large, dirty, or crushed soft tissueinjuries Severe combat stress symptoms orpsychosis

Priority 3—Minimal (Green)

Casualties with minorproblems that are notexpected to deteriorate

Uncomplicated closed fractures anddislocations Uncomplicated or minor lacerations(including those involving tendons,muscles, and nerves) Frostbite Strains and sprains Minor head injury (loss ofconsciousness of less than 5 minuteswith normal mental status and equalpupils)

Priority 4—Expectant(Black)

Casualties who are notexpected to survive orwho are already dead.Resources should not beused on these if thereare higher prioritycasualties.

Traumatic cardiac arrest Massive brain injury 2nd or 3rd degree burns over 70%of the body surface area Gun shot wound to the head with aGlasgow Coma Scale of 3

There will be higher and lower priority casualties in each category. Grading may besubjective and requires the discretion of the medic or triage officer, especially duringa Mass Casualty Incident.

ANNEX B—MASS CASUALTY EVENTS AND TACTICAL TRIAGEA casualty will be categorized in one of four categories:


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Assessment during a mass casualty incident will be abbreviated to a few simplequestions and a quick visual inspection.

Where do you hurt?

Can you take a deep breath?

Visual for life threatening bleeding.

These simple questions can give you an indication of a casualty's LOC, airway,breathing, and circulation. The most important factor is to identify and treat life-threatening bleeding.

Very serious casualties may distract the caregiver, but one must realize the situationand capabilities of the treatment resources. The goal is to the most good for thegreatest number of casualties. Resources should not be wasted on a casualty whowill likely not survive.

Casualty grading systems may change depending on the country providing theCASEVACs on that particular operation.


ANNEX C—SCENARIO-BASED TRAINING

While the guidelines for combat casualty management provide a basic start point, there isno golden plan that will encompass all situations. The guidelines provided within thisDispatches are not intended to be rigid in their application, otherwise we will have tradedone set of problems for another. The need for a degree of flexibility in our approach tocombat casualty management has led to the development of scenario-based planning,which requires mission commanders to develop viable scenarios with the assistance oftheir medics. Scenarios should be war-gamed and rehearsed in the mission-planningphase. Suggested criteria for scenario planning are as follows:

Is there a relatively high probability of this scenario occurring?

Has this type of scenario occurred on previous missions?

Plan for worst-case scenarios, those that present a difficult medicalmanagement problem.

Plan for scenarios that require both tactical and medical decisions.

Plan for scenarios that require a major departure from traditional civilianmedical practices.

Scenarios should take into account the criticality of the mission, the anticipated timeto evacuation, and the environment in which the casualties may occur. Clearly, it isnot be possible to imagine every situation that may occur. Nonetheless, this shouldnot deter planning for probable and difficult scenarios. Reviewing several of themost likely and worst cases is a valuable addition to the planning process and shouldbe included in battle procedure. The guidelines herein, however, should beconsidered advisory and not directive in nature.

The following scenarios are extracted from Tactical Medicine for Naval SpecialWarfare CD-ROM. Each scenario can be discussed and 'war gamed' using theinformation in this publication. You can use these as guidelines to follow whencreating your own scenario based approaches. Experience on the TCCC pilotcourse demonstrates that it is in war-gaming scenarios that all the trainingcomes together and becomes fully understood by all those involved. It is herethat the effectiveness of TCCC is truly revealed. This type of training shouldideally be implemented on all training exercises. Consider all three phases ofcombat casualty care for each scenario.

Examples of Scenarios:

Scenario 1:

During a reconnaissance patrol conducted by a four-man element, theelement leader trips a booby trap. The booby trap also injures the radioman

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We must also have the intellectual agility to conceptualize creative, usefulsolutions to ambiguous problems…This means training and educating our[soldiers on] how to think, not just what to think.

—Gen Peter Schoomaker, Commander-in-Chief, USSpecial Operations Command


and the automatic weapons man. The element leader is unconscious andbleeding from the lower back and the back of both legs. The radiomanreceived the full frontal blast of the booby trap and has no pulse orrespirations. The automatic weapons man received fragmentation woundsto his lower left leg. He is dazed by the blast effects.

The point man, who is also the [patrol] medic, is uninjured but dazed. Hemust respond quickly because of enemy reaction forces in the area.Somehow he must treat the wounded, get the element ambulatory, andbegin evasion and recovery (E&R) operations. Primary and secondarycommunications were knocked out in the blast and the only functioningradio is his inter-squad radio.

Scenario Notes and Considerations for Discussion:

One man must treat two injured personnel.

Where should the [patrol] medic be in the order of march in small [recce]elements? If the medic has a talent for point, should he be used in that role?

All members of the element must be well versed in the E&R plan. The pointman must take charge.

The element leader must be treated and transported by the point man andrear security. What issues/questions would arise if the rear security werenot ambulatory?

In this case, does the [patrol] medic need to hide the body of the deceasedmember, initiating a GRAZE report, or should he immediately take the rest ofthe element into the E&R system?

What communications issues arise from the loss of the primary radio?

Scenario 2:

A [Company] element is assigned to secure a small airfield as part of an invasionforce. The CASEVAC capability is uncertain. The element is taken under fire,resulting in a standoff with both sides maintaining effective enemy fire. Twelvecasualties result, including four dead and eight wounded. Three have chestwounds: one is unconscious; one conscious but with respiratory distress; the thirdis stable. In addition, there are two abdominal wounds—both are stable; oneshoulder wound—severe hemorrhage; one leg wound—stable; and one facewound with oropharyngeal hemorrhage.


This scenario features multiple trauma within an ongoing engagement. Nowwhat?

There may be a gray area here between the Care Under Fire phase and theTactical Field Care phase. Because of an ongoing and lengthy engagement,where is the medic(s) going to provide the best casualty care: engaging theenemy or treating the casualties themselves.

How deep should the medic delve into treatment? What are themedic's priorities?

Scenario 3:

A 12 man night desert patrol is moving across a dry stream bed in 4 Desert Assault

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Vehicles (DAVs) on the second day of their patrol. The DAVs are moving at nightbehind enemy lines on a scud hunting mission. There has been no contact withthe enemy, but it is believed they are operating in the area in Brigade strength.One of the vehicles hits a Soviet anti-tank mine. The vehicle flips and rolls. Thedriver is pinned in the DAV by the wreckage. It appears that both his legs arecrushed. Initial assessment suggests that he sustained bilateral femur fractures.The patrol leader is thrown from the vehicle and is unconscious. There is noobvious sign of injury on initial assessment. His pulse is 70 regular, respirations12, and he is not responsive to pain stimuli, pupils are equal, round and reactiveto light and accommodation. The gunner received fragmentation wounds to theabdomen and the chest; he is conscious and talking, feeling cold, having difficultybreathing, with a pulse of 100, respiration 15. CASEVAC is unavailable for about12 hours and must come from 100 miles away. Land escape and evasion is to thesame point.


Injuries must be treated and the casualties moved by the other assets in thepatrol or call for CASEVAC.

Management of the casualties, including one likely fatal injury in an isolatedcombat situation, is a point of discussion.

The loss of the patrol leader, at least temporarily, is an operational issue.

Another issue is the timing and management of medical care in the light ofpossible enemy reaction. Blunt trauma requires spinal precautions if possible.

Scenario 4:

A Platoon-size element plans an interdiction operation in arid, mountainousMiddle Eastern terrain. The targets, two trucks with Surface-to-Air missiles, areexpected in several hours with an estimated strength of 10 men armed withautomatic weapons in two Armoured Personnel Carriers (APCs). The plan is toconduct a helicopter insertion some six miles from the target: extraction can beconducted closer to ambush site. While the patrol is in the ambush position, oneteam member is bitten on the leg by an unidentified snake. Over the next15 minutes, the pain becomes increasingly severe and the injured man becomesdizzy and confused. The target convoy is expected within two hours.


There is a direct conflict in this scenario between what is best for the casualtyand the completion of the mission. Does the team remain in place or do theycall for an immediate CASEVAC?

What immediate care should be rendered to the casualty?

Scenario 5:

A Parachute Company is tasked with an airfield seizure mission. They are to jumpinto the airfield from CC-130 aircraft. On the jump run, with personnel standingup and ready to exit, the lead aircraft is struck by anti-aircraft fire. Severaljumpers are injured—the first has lost his leg at the hip, the next has suffered alarge shrapnel wound to the chest. The next two jumpers suffered minor facialinjuries from flying shrapnel. One of these men is blinded by shrapnel in one eye.All the injured parties remain in the aircraft (no one fell out). The aircraftsustained minor damage, but the aircraft commander aborted the jump run. Theother aircraft managed to deliver the rest of the company.

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Historical Precedence: During Operation JUST CAUSE in Panama, the RangerCompany tasked with seizing Rio Hato airfield suffered massive casualties. TwoTF-111's dropped 500 lb bombs offset from the airfield before the Rangersstarted their jump run. The bombs alerted the Panamanian defenders, whomanned their anti-aircraft guns and were ready for the C-130s as theyassaulted the field.

The aircrew or the other jumpers on board the aircraft must treat thecasualties. There is bleeding to be stopped and a major chest wound to beresolved. The blind man has to be calmed and moved away from the door.Operationally, the issue is whether to make another jump run or not. Airfieldseizure is an operation that requires surprise and the application of suddenforces. The soldiers on the ground need the rest of the people in this aircraft.

Scenario 6:

A section-sized element (approx 10 men) is returning from patrol in a highmountain area after a heavy snowfall, in intermittent white-out conditions. Theyare about six km from their base camp. While traversing a slope, an avalanchesweeps down on them burying all but four. The patrol leader and his signallerwere in the lead of the formation and escaped being buried. The radio is intact.The four remaining members have located and dug out four of the six missingmembers of the patrol. All of the injured personnel are gradually slipping intohypothermia—one has a fractured femur and a simple forearm fracture; thesecond man has a broken ski pole driven into his abdomen; the third had a brokenjaw; and the fourth has two broken legs, one of which is an open lower legfracture. CASEVAC by air is not feasible due to worsening weather conditions.Better weather is not forecast for another 48 hours.


The initial concerns are locating the other two missing personnel, if possible,and treatment of the injured. All members were equipped with avalanchetransceivers, probes and shovels.

The follow-on concerns are movement back to camp, if possible, orbuilding some type of survival shelter (e.g., snow cave) to weather thedeteriorating conditions.

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ANNEX D—TRAINING CONSIDERATIONS FOR MEDICALPERSONNEL

Train medics in day and night, mounted and dismounted land navigation.

Train medics in unit SOP's in regards to all aspects of warfare. Eg. Occupying apatrol base, break contact drills, actions on flares etc.

Train medical platoon leaders in the basic fundamentals of tactical operations.This will allow a better understanding of what is to be supported.

The use of non-standard evacuation platforms should be considered. Think interms of non-standard vehicle loads versus standard vehicle loads: oneambulance carries four patients, while a ten-ton truck will carry 12 or more.Medical combat power is increased.

Rehearse CASEVAC.

Perform a route recce of all possible evacuation routes.

Train and conduct CASEVAC during combat operations. Train as you fight.

Train to treat casualties in MOPP 5 state of dress.

Develop a vehicle marking system to identify vehicles carrying casualties. Plan fornight identification.

Use casualty tags.

Gather intelligence. In Afghanistan, SOF Medics performing humanitarian dutiesstated that the best source of information about Al Quaida and Taliban came fromthe populace that they treated.

For urban operations:

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An efficient medical service is a great conservator of manpower, as, by itsinsistence on the principles and practice of hygiene, it keeps the troops healthyand avoids wastage from sickness. It is a great incentive to good morale, asthey know that, if they are wounded, they will be well looked after.

—Australian Major General W.B. 'Digger' James,AO, MBE, MC, OStJ

If combat medics are not readily available in the troop area, patients may beevacuated on any suitable vehicle already moving to the rear, such as arecovery vehicle or maintenance vehicle.

—Extract from FM-8-10-4, Medical PlatoonLeader's Handbook


Rehearse evacuation downstairs, from rooftops and over obstacles. Alsoconsider practicing, under engineer supervision, the safe removal of rubblefrom atop an injured person.

Be prepared to advise unit leadership on location, number and use of patientcollecting points.

Ensure that someone has been trained to take your place if you are injured,particularly if working at the platoon level.

Refresh yourself on the indicators of evidence of disease among your soldiers.The goal is to stop any epidemic before it commences, if at all possible.

Medical personnel need to be involved in the planning of urban operationsfrom the start. Medical intelligence must also be stressed as the healthhazards to troops entering any city need to be considered.

Most North Americans are epidemiologically ignorant and will accept any andall municipal water supply, if the system is intact. Local water suppliesshould be treated as if contaminated until proven safe by the appropriatemedical authorities.

Seizure of locally available food items and regionally produced beverages canbe dangerous, as the potential of contamination remains high unless approvedby veterinary food inspection specialists. As an example, soft drinks maycontain hepatitis or typhoid organisms.

During the Second World War, the US 14th Medical Laboratory studied Koreanalcoholic beverages and found more than 50% contaminated with methanol.

Human and animal remains need to be disposed of immediately, as they willattract all manner of vermin very quickly.

Carry sufficient first aid materials for yourself in the event you become isolatedfrom your unit. In particular, the most common injuries are burn, shrapnel andsniper wounds: extra burn dressings and splint materials are essential.

Be aware of the manual evacuation techniques before entering the city.

Eat and drink only those rations and beverages that have beenmedically approved.

Respect the city and civilian property, in particular their food and watersupplies, and their sanitary facilities. This is to prevent the outbreak of diseaseamong the local population and its spread to you and your unit. In particular,fire and air support planners should attempt the preservation of medicalfacilities, utilities and sanitation facilities within the city, if their preservationdoes not compromise operations.

Historical evidence suggests that aerial evacuation should be limited tooutside the city, with armoured ground transport within the city beingthe preferred method.

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GLOSSARY OF ACRONYMS

AH Attack HelicopterAPC Armoured Personnel CarrierATLS Advanced Trauma Life Support

BTLS Basic Trauma Life SupportBVM Bag Valve Mask

CASEVAC Casualty EvacuationCF Canadian ForcesCSAR Combat Search and Rescue

DAV Desert Assault Vehicle

EMS emergency medical servicesEMT Emergency Medical TechnicianE&R Evasion and Recovery

FARP Forward Area Refuelling Points

GCS Glasgow Coma Scale

Hb HemoglobinHLZ Helicopter Landing ZoneHSD Hypertonic Saline and Dextran

IO InterosseousIV Intravenous

LOC Level of ConsciousnessLMA Laryngeal Mask AirwayLR Lactated RingersLSVW Light support vehicle wheeled

MEDEVAC Medical EvacuationMOPP mission oriented protection posture

NATO North Atlantic Treaty OrganizationNG NasogastricNPA Nasopharyngeal AirwayNPO Nothing By MouthNS Normal SalineNTM Notice to Move

OPA Oropharyngeal AirwayOPSEC Operations Security

PFC PerfluorocarbonPPE Personal Protective Equipment

SOF Special Operations ForceSWAT Special Weapons and Tactics

TCCC Tactical Combat Casualty CareTEMS Tactical Emergency Medical Support

UMS Unit medical section OR Unit medical station

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REFERENCES / SUGGESTED READING LIST

“Tactical Management of Urban Warfare casualties in Special Operations”.Proceedings of the 1998 Meeting of the US Special Operations MedicalAssociation. 1998.

Sobczak, and Freshour. “Level One Combat Health Support (CHS) for the LightInfantry Deliberate Attack”. U.S. Army Medical Department Journal,September–October 1997

Butler FK, Hagmann J, and Butler EG. “Tactical Combat Casualty Care in SpecialOperations”. Military Medicine 161; Special Supplement; August 1996

Special Operations Forces Medical Handbook, Teton NewMedia and The GenevaFoundation. 2001.

Operational Emergency Medical Support (OEMS). An independent U.S. school ofoperational emergency medicine

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Author

Cpl Chris Kopp

Contributors/Professional Advice:

Capt Roger King, MD, CCFPLCdr Dennis Filips MD, FRCSC, General/Trauma Surgeon, 1 CF HospitalMaj Nick Whithers, OC 21 CF Health Services Centre ComoxCapt Luft, 3 PPCLICapt Strong, 3 PPCLI

ALLC Coordinator/Editor

Maj C.J. Young, SO Ops


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