Tactical Assesment for Non medical personnel

[Armymedic]

I developed this protocol in response to the request of my team here in Afghanistan. All 13 other mbrs completed the Cbt First Responder course, and asked for more medical training and specific direction towards exactly when and why each of the skill are to be used. I developed it in coordination with our team SOP and then tailored it towards a completely generic protocol for any nonmedical pers who do not have medical assets with them, or if it is the medical assets which are the casualties. It is also designed so that at the end of the Tactical Fd care stage for all casualties to be handed over to med pers. I hope it will be eventually adopted for the CF wide new tactical casualty course.

I have 12 Cbt arms Snr NCOs and officers on the team, about half of which had input to the final draft which I have below. I have also credited the sources in which I have taken ideas from to complete the protocol.

Feel free to comment below, or pm me with thoughts. Remember, its meant for all deployed army pers who have taken the Tactical Combat Casualty courses less qualified medical pers.

Tactical Assessment for Nonmedical Personnel

Care Under Fire

1. React to fire
   a. seek cover
   b. return fire as trained
   c. attempt to neutralize threat.

2. Contact casualty
   a. direct the casualty to perform self aid
   b. direct the casualty to return fire if able
   c. if casualty is unable to return fire, tell them to lie still

3. Protect casualty from additional wounds
   a. if casualty is able to move direct them to cover
   b. if casualty is unable to move, attempt to recover casualty to safe area

4. Once casualty is in safe area, assess LOC / Airway by asking â Å“Where are you hit?â ?
   a. if not alert, disarm

5. Stop any life threatening bleeding
               a. with tourniquet for extremity
               b. with direct pressure on body

6. Reassure casualty

7. Take casualty with you or position casualty when you leave
   a. place in a fire position with weapon if able
   b. recovery position if decreased LOC

8. Return to fight as required

Tactical Field Care (No longer under threat)

1. Send Reports
   a. contact report
   b. initial cas evac request â “ 9 line Medevac Request

2. Assess LOC using AVPU scale

3. Airway
   a. open, as trained using modified jaw thrust or alternate method
   b. clean, using bulb suction as indicated
   c. secure with NPA as indicated

4. Breathing
   a. assess depth, rate and effectiveness

5. Circulation
               a. check pulse at wrist for rate, if no pulse at wrist, check at neck
               b. stop all known bleeding

6. Chest
   a. open vest and armour and inspect and feel the chest
   b. assess need for needle decompression:
      - difficulty breathing with
      - decreased loc
      - no pulse at wrist
      - signs of penetrating chest trauma

7. Continue full body survey including back for any other wounds

8. Dress all wounds

9. Evacuate
   a. update 9 Line
   b. redistribute ammo and mission essential kit
   c. prepare to evac cas by avail means



References:

Cpl Kopp
â Å“Tactical Combat Casualty Care: A Proposalâ ? Dispatches The Army Lessons Learned Center Vol 10 No. 2 Nov 04

Various Authors:
â Å“Tactical Combat Casualty Careâ ?
Prehospital Care in the Tactical Environment
The Committee on Tactical Combat Casualty Care
For Chapter 17: Military Medicine, in The Prehospital Trauma Life
Support Manual, Fifth Edition
21 Feb 2003 Draft

LCol Kile
Petawawa Tactical Combat Casualty Care June 03

Maj Storrier
Petawawa Tactical Combat Casualty Care Oct 04

Capt Macdonald
TFK 3 HSS Coy Cbt First Responder course Feb 05

WO Fisher
CANTC Det SOP Mar 05

 

[Armymedic]

Survey awaiting approval, before possibly becoming TF SOP for TCCC qualified pers.

 

[slim300]

This is well thought out.  The only thing I can think of to add is in step 4 of care under fire, add actions on for compromised airway.  This would likely be as simple as putting the casualty in the recovery position or repositioning the head.

I expect you'd agree that a basic airway intervention like that is worthwhile in the care under fire phase... rolling someone into the recovery position is all to easy, and a casualty can only go 4 minutes without an airway before brain damage starts.

Again, good work. BZ.

 

[Armymedic]

Care under fire is just that, quick care you do while doing your best to not be killed.

While it may be noble to roll the possibly unconscious cas to the recovery position, by doing so you will expose yourself to greater danger and going against the principle of having the cas lay flat to avoid being a target.

By log rolling the cas, you mark him to the enemy...at that would be all bad.

 

[TCBF]

"By log rolling the cas, you mark him to the enemy...at that would be all bad."

I am confused.  If you are a medic, you don't "Return to the fight as required"

If you are not a medic, you should be laying down fire and clearing the position, not laying out bandages.

No point saving one life, if only to have him bayonetted by the enemy as they roll over your position because some guy(s) put down their weapon(s) to patch a buddy.

We have a Battle Drill for re-org, do we not?

 

[Armymedic]

If you are not a medic, you should be laying down fire and clearing the position, not laying out bandages.
No point saving one life, if only to have him bayonetted by the enemy as they roll over your position because some guy(s) put down their weapon(s) to patch a buddy.
We have a Battle Drill for re-org, do we not?

Exactly my point....as this is an assessment for NONmedical personnel qualified tactical casualty care.

 

[Fraser.g]

"By log rolling the cas, you mark him to the enemy...at that would be all bad."

I am confused.   If you are a medic, you don't "Return to the fight as required"

If you are not a medic, you should be laying down fire and clearing the position, not laying out bandages.

No point saving one life, if only to have him bbayonetedby the enemy as they roll over your position because some guy(s) put down their weapon(s) to patch a buddy.

We have a Battle Drill for re-org, do we not?

By utilizing the TCCC there will be an established drill as to when you can and should come to the aid of a buddy. Yes We have a Battle Drill for the Re-Org (Consolidation) but the only time during that drill that wounded were addressed was in the Ammo Cas State.

For the first time in the Battle Drill this acknowledgesthat casualties happen during the fire fight (Surprise!) and not at the end just before the re-org.

It is human nature to go to the aid of a buddy in pain. The only way to combat that urge is to drill an SOP into the combat arms.

All this does is set up an SOP for when you start to take casualties in an operational environment.

GF

 

[slim300]

Armymedic,

It sounds like you are contradicting your own SOPs in your reply.  I fully understand the concept of care under fire.

Your SOPs:
4. Once casualty is in safe area, assess LOC / Airway by asking â Å“Where are you hit?â ?
  a. if not alert, disarm

If you already have the casualty in a safe area and are close enough to assess airway and LOC and disarm if necessary, how does it put anyone at greater risk to put someone in the recovery position, which is very close to the prone position anyway.  I would have to say that in such a circumstance, leaving someone asphixiate on their tongue is more dangerous than the 2 sec of slightly greater exposure to enemy it takes to roll a supine casualty.

 

[TCBF]

When do you treat the cas?     When the enemy are dead.

Exceptions:   When there is nothing else (shooting, moving, communicating) that you should be doing at that moment, and as long as treating the cas will not impinge on your ability to move, shoot, or communicate the INSTANT you need to do so.

Otherwise, you take needless casualties.

Kill the enemy, then treat the cas.

 

[Armymedic]

Actually it is covered...
both points by TCBF and Med eh!

7. Take casualty with you or position casualty when you leave
  a. place in a fire position with weapon if able
  b. recovery position if decreased LOC

8. Return to fight as required

 

[TCBF]

"1. React to fire
  a. seek cover
  b. return fire as trained
  c. attempt to neutralize threat.

2. Contact casualty
  a. direct the casualty to perform self aid
  b. direct the casualty to return fire if able
  c. if casualty is unable to return fire, tell them to lie still

3. Protect casualty from additional wounds
  a. if casualty is able to move direct them to cover
  b. if casualty is unable to move, attempt to recover casualty to safe area"

OK, my bad, I have not clearly posed my question.All of the above, up to sub para 3a, can be done while you are fighting.  To go from 3a to 3b is a major shift in your main effort.  You now have someone who should be paying attention to the enemy directing his attention to a casualty. 

TO ENSHRINE THIS AS AN SOP AS WRITTEN IS IRRESPONSIBLE.

It is up to the commander on the ground to decide at what point casualty care (saving individuals) takes precedence or effort away from destroying the enemy (saving the unit).  It is not up to an SOP. 

The local commander - fire team leader and up - has to decide at what point fighters (not medics) will treat cas rather than fight.

 

 

[slim300]

Armymedic,
Fair enough... my original point was just to lay it out more clearly.  If you lay it out as IAs like rifle drills, I believe the SOP would be more user friendly.  As in, assess airway--> if compromised, put cas in recovery position.  Certainly not that big a deal.

In response to TCBF:
Of course caring for casualties should be under the direction of leadership, as should just about anything a soldier does during combat.  However, the notion that such an SOP is irresponsible is naive.  First of all, not all combat casualties are taken in the midst of a section attack on a lone enemy trench, we don't practice war by attrition so waiting until all the enemy are dead is a flawed point of view to start with.  I can think of several situations where a single rifle could be spared for a matter of 30 sec to care for buddy.

Secondly, assuming all casualty care should wait until reorg entirely ignores the human factors: casualties have a devastating impact on the morale of a unit, having a practiced drill to perform when your commander tasks you to care for the downed man can help maintain the effectiveness of your whole section/unit.  There are enough clichés in the movies about the reason we fight being the buddy in the next trench that you'd think that people would have figured out that it's a bad idea to let buddy die unnecessarily.

This kind of SOP just serves a guideline for commanders and soldiers-alike to know how to respond.

Cheers.

 

[Armymedic]

OK, my bad, I have not clearly posed my question.All of the above, up to sub para 3a, can be done while you are fighting.   To go from 3a to 3b is a major shift in your main effort.   You now have someone who should be paying attention to the enemy directing his attention to a casualty.  

TO ENSHRINE THIS AS AN SOP AS WRITTEN IS IRRESPONSIBLE.

It is up to the commander on the ground to decide at what point casualty care (saving individuals) takes precedence or effort away from destroying the enemy (saving the unit).   It is not up to an SOP.  
The local commander - fire team leader and up - has to decide at what point fighters (not medics) will treat cas rather than fight.

To not have any SOP at all is also irresponsible.....

you speak of only one small section of our doctrine, I am looking at guidance for all of the army in all its roles and tasks. And in direct response to your points, nowhere does it say that the person who takes this action has to be the subunit in direct contact...it could be the follow on sections, platoons or even companies who take care of the casualty....that is still care under fire.
To directly address your concern;
To "attempt to recover cas to a safe area" maybe to pull him forward a few feet to an area where he can not be hit again, and the key word is "attempt". I leave it with that word because it allows for the flexibilty where the mission dictates whether that "attempt" can be safely made.

By taking the actions I outline in the Care Under Fire Phase, you can save 30% of all battlefield casualties from dying.....to not make that attempt at all, would also be irresponsible.

And let me reemphasise, this is for the nonmedical people...medics are usually back a bound from the contact, so it WILL be the leaders who will decide the actions that must be undertaken. I didn't just pull this out of my hat, it was done with the consultation of 3 Infantry Sr NCOs and 2 Infantry officers as well. The primary one being named above as a reference....it will fit into doctrine.

again, my main point in rebuttal....

To not have any SOP at all is also irresponsible.....

 

[Grunt_031]

When do you treat the cas?    When the enemy are dead.

Remember Somalia, US Rangers. Your Care under fire can last hours and hours.

 

[JANES]

"Any casualty management plan should be considered advisory rather than directive in nature"
Capt (N) Frank Butler

 

[TCBF]

"we don't practice war by attrition"

Wanna bet?  Stay in your arcs, now...

"so waiting until all the enemy are dead is a flawed point of view to start with."

Depends on the sit, obviously, if I CAN do something about cas, I will - believe me, I will - , ASAP, for all of the good reasons you guys have listed above.  BUT, "Mission First" sometimes actually means "Mission First".  If we teach , practice, and assess our soldiers in scenarios where there will ALWAYS be someone who will be able to assist the cas before an engagement is finished, we will be doing them a dis-service.

I agree, an SOP will be handy, but we need a BATTLE oriented SOP, not a CASUALTY oriented SOP.

  "I can think of several situations where a single rifle could be spared for a matter of 30 sec to care for buddy."

I agree.  Perhaps even in a majority of situations.  And you can bet we will all try and find a way to make that happen.  But to enshrine it as an SOP gives it the authority of a DRILL.

"Any casualty management plan should be considered advisory rather than directive in nature"

There we go.  Words to the effect that  " re-deploying combat power from the battle to casualty care is a command decision, not a medical one" may be usefull between para 3a and para 3b.

 

[JANES]

Let's see here...

According to TCCC guidelines:

"Objectives of tactical casualty managment:  Treat the casualty, prevent additional casualties, complete the mission - not necessarily in that order."

"The priority of the mission may take precidence over the welfare of the casulaty"

"Care Under Fire phase:  'Firepower may be the best medicine'"

"Drills" need to be in individual skill, such as recognition of life threatening bleeding, and tourniquet apllication, casualty rescue should not be an SOP, but rather a TT&P.  You need to practice casualty rescue to have the skills in your tool box, as stated prior - if the commander on the ground deems it appropriate to perform a rescue given the situation, it cannot be a rule.

Remain flexible, with the skills to due what is appriopriate at the time given the situation.

 

[JANES]

"We can not trade one set of rigid guidelines for another"
- Capt (N) Frank Butler

 

[Dale Turner]

Just my two cents...
One of the first things we are taught whether you're Reg or Res is scene safety. That being said "scene safety" is becoming a relative concept. In a combat sit. we as medics are just as responsible to make the scene safe as our infantry collegues are. You cant effectively treat a casualty when you're still under effective fire. So I agree with the statement that sometimes the best treatment is to return fire.

Also that being said I think it's imperative that our training scenarios reflect a combat flavour to them.  Now some will say that we'll need to involve infantry units to facilitate this type of training. However we've all seen CSS convoys coming under attack from insurgents in Iraq.  Some of these CSS convoys did'nt have any infantry to provide security.  So isn't it reasonable to train as Fd Ambs in convoys that come under attack from the unconventional enemy and throw in the TCCC sops as well?

Again just my two cents. :soldier:

 

[TCBF]

Not to digress from the original thread, but, yes Battle Task Standards covers that:

B-GL-383-002/PT-023 Battle Task Standards - Medical: pg. iii, para 5.

  "These Field Amb BTS emphasize aspects unique to the provision of medical support.  Combat Service Support BTS 1001, " ..."4101" (Defend)  ...  "4316"  (Conduct Road Movement)...."...are of great relevance to Fd Amb operations and should be consulted where a more detailed breakdown of certain tasksis required."

BTS L4316 D/F Conduct Road Movement:  " 6.  i: The packet reacts to air attack or ambush IAW BTS 5004, Defend Against Air Attack or BTS 5006, React to Ambush."