Module 3: Care Under Fire

During this module, we will define and discuss Care Under Fire (CUF).

The actions taken during and the basic principles of Care Under Fire apply to all levels of training. All Service Members (ASM), Combat Lifesaver (CLS), and Combat Medic/Corpsmen (CMC) training provided trainees with the same information that we’ll be discussing in this module. This is important, because everyone needs to be working towards the same objectives in this phase of operations where the environment is unstable and threats are still active.

There are five cognitive and four performance learning objectives for the Care Under Fire module. The cognitive learning objectives are to describe the role of fire superiority and how the tactical environment impacts Tactical Combat Casualty Care (TCCC), the actions required before engaging with a casualty to prevent harm or additional casualties, appropriate actions and priorities to treat and move casualties in Care Under Fire, the importance of early application of limb tourniquets, and the principles, advantages, and disadvantages of one-person drags/carries or two-person drags/carries in Care Under Fire.

The performance learning objectives are to demonstrate one-handed tourniquet self-application and two-handed tourniquet application to a casualty, and to demonstrate the one-person and two-person drags and carries of a casualty in Care Under Fire.

Care Under Fire is the first of three phases of TCCC. It is the lifesaving care provided while still under active enemy fire or threat.

Care Under Fire—or in the case of a noncombat environment, Care Under Threat—is the care rendered by the first responder, CLS, CMC, or Combat Paramedic/Provider (CPP) at the point of the injury/wounding while still under effective hostile fire. In this phase, the scene is not safe, and the overall priority is to establish scene safety in the form of fire superiority or control of any threats from a noncombat environment.

Actions are prioritized to suppressing enemy fire and gaining fire superiority to prevent further harm or additional casualties, identifying and controlling life-threatening bleeding, and moving the casualty to cover.

The TCCC Guidelines state that the basic management plan for Care Under Fire is:

1. Return fire and take cover.
2. Direct the casualty to remain engaged as a combatant if appropriate.
3. Direct the casualty to move to cover and apply self-aid if able.
4. Try to keep the casualty from sustaining additional wounds.
5. Stop life-threatening external hemorrhage if tactically feasible.
6. Move the casualty to cover, if the casualty is unable to move.

The mission does not stop just because there is a casualty. Most battlefield casualty scenarios involve making medical and tactical decisions rapidly. In the combat environment, there is no “time-out” when casualties occur. Good medicine can sometimes be bad tactics; doing the RIGHT thing at the WRONG time can get you and your teammates killed or cause the mission to fail.

The order of initial actions will be dictated by the tactical situation. Little time is available to provide casualty care while under effective enemy fire.

#### REMEMBER:

- Do not become a casualty!
- Assess the situation and the risk.
- Suppress enemy fire and gain fire superiority first.
- Communicate with and direct the casualty to return fire, move to cover, apply self-aid, and develop a plan before moving to care for a casualty under fire.

The TCCC Guidelines have become the standard of care for prehospital trauma within the DoD for both medical and nonmedical first responders. As such, the methodology and subsequent training programs are intended to be applied to any high-threat or all-hazard situation encountered by a Servicemember whether in combat or during normal duty activities.

Fundamentally, the principles of TCCC apply whether in ground tactical combat, aboard a sea vessel, at a deployed staging base, or even at home station facilities. The principle of first suppressing enemy fire, subduing an active shooter, extinguishing a shipboard fire, or reducing life threats prior to rendering medical treatment is applicable across the full range of military operation at home or abroad. Additionally, the principle of controlling immediate life-threatening hemorrhage remains the only recommended medical intervention until the threat is suppressed or controlled.

It is also important that the TCCC Guidelines be relevant in terminology used throughout the entire DoD. Joint lexicons ensure interoperability between the Services, unit formations, and individual Servicemembers for key terms used in support of trauma care, operational medical planning, performance improvement, and research across the spectrum of military operations.1

Additionally, the use of “Care Under Fire/Threat” was integrated into the TCCC All Service Members (TCCC-ASM) curriculum in 2019 by the ASD, Health Affairs–chartered working group based on guidance from Joint Trauma System personnel.1 This action was specifically included to ensure acceptance and compliance by all the military departments.

Simply stated, the role of fire superiority is to return fire, take cover, and gain fire superiority. Taking these actions is a priority and will help in containing the immediate threat; obtaining fire superiority from point of cover minimizes the risk of new casualties and additional injuries to existing casualties while completing the mission.

Personnel may need to assist in returning fire instead of stopping to care for casualties, and wounded Service members who are exposed to enemy fire should be directed to continue to return fire.

Entering a kill zone to treat or evacuate a casualty is rarely the best action and may lead to additional casualties; establishing fire superiority supersedes those actions.

The best medicine on the battlefield is fire superiority!

The order of these four actions really depends on the scenario, but generally, scene safety is paramount. If the scene is safe, and there is life-threatening external hemorrhage, your first step could be tourniquet placement. Each scenario is different, and the ordering of these actions could vary.

There are four major areas for action:

### 1. Scene Safety

First, you must ensure the scene is safe for you to enter. You can help others who may be working to secure the scene, or you may have to do what you can to make the scene safe to enter (return gunfire, firefighting, etc.). You can’t risk your personal safety, the risk of injury to other personnel, or the safety of your casualty.

### 2. Casualty Movement

Move the casualty to a safer area due to a real or potential threat that exists in the environment. In that case, you must quickly develop a casualty movement plan that takes into account these important considerations: the location of the nearest cover, how best to move yourself or the casualty, the weight of the casualty, and the distance to be covered.

### 3. Stop Life-Threatening External Hemorrhage

Place one or more hasty tourniquet(s) (in a “high and tight” manner) on an arm or leg to control life-threatening external hemorrhaging. This should be accomplished in less than 1 minute. If the casualty is conscious, you may direct the casualty to render self-aid and apply a tourniquet to him/herself, if they have one.

### 4. Proper Communication

Once you are able to reach the casualty safely and have taken any other precautions through proper communication, you must:

- Communicate with the casualty: as soon as possible, maybe even before you have moved the casualty to a safe area, communicate with the casualty to determine if they are awake, confused, or disoriented. If they are awake, let them know you are there to help.
- Request assistance: get help from first responders or other medics, if available. Rarely are you alone in these circumstances.

After establishing fire superiority in order to avoid additional casualties and additional injuries to existing casualties, treatment priorities can be addressed. Per the TCCC Guidelines, these are:

1. Extracting casualties from burning vehicles or buildings (if applicable).
2. Stopping life-threatening hemorrhage using limb tourniquets (if tactically feasible).
3. Moving casualties to cover whenever possible.

Other care should be deferred to the Tactical Field Care phase.

Follow unit standard operating procedures for removing/extracting casualties from unsafe or burning vehicles or buildings and move them to places of relative safety. If fire is involved, put out the fire, if possible, and do what is necessary to stop the burning process.

If the casualty is responsive and able, direct them to return fire, move to cover (if possible), remind them to remain engaged as a combatant (if appropriate), and self-apply a tourniquet if able or when tactically feasible.

They should use a CoTCCC-recommended tourniquet for life-threatening hemorrhage amenable to a limb tourniquet, applied “high and tight” as quickly as possible to stop bleeding (within 1 minute, ideally), and then re-engage in establishing fire superiority.

If the casualty is unable to move, have them re-engage in helping to establish fire superiority, if possible, and depending on the tactical situation, they may still be able to apply self-aid without significant risk of exposing themselves to the risk of additional injuries.

As soon as it is tactically feasible, every attempt to stop life-threatening external hemorrhage should be made. Some basic principles include:

- Direct casualty to apply their own tourniquet, if able.
- Use a Committee on Tactical Combat Casualty Care- (CoTCCC-) recommended limb tourniquet for hemorrhage that is anatomically amenable to tourniquet use.
- Apply the limb tourniquet over the uniform clearly proximal to the bleeding site(s).
- If the site of the life-threatening bleeding is not readily apparent, place the tourniquet “high and tight” (as proximal as possible) on the injured limb.

If a casualty is responsive but cannot move, and the situation provides a window of opportunity, a rescue plan should be devised and executed when tactically feasible. Determine the risk to rescuers, consider your assets, and make sure all personnel understand the movement plan.

Do not put responders at risk if it can be avoided.

If cover is not available or the wounded Service member cannot move to cover, refer to your unit’s SOP or tactics, techniques, and procedures.

To help introduce the topic of bleeding control in the Care Under Fire phase and also provide a general overview of limb tourniquets, watch this short video.

# CARE UNDER FIRE / THREAT OVERVIEW

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#### Remember:

- If you can do only ONE thing for the casualty, identify and stop life-threatening bleeding to keep them from bleeding to death.
- Extremity hemorrhage is the most frequent cause of preventable battlefield deaths. Over 2,500 deaths occurred in Vietnam secondary to hemorrhage from extremity wounds. A large number of deaths in Iraq and Afghanistan were also seen from hemorrhage.
- Injury to a major vessel can quickly lead to shock and death.

It is important to understand how to perform a visual blood sweep to distinguish life-threatening hemorrhage from minor bleeding. The following are examples of when bleeding is considered life-threatening:

- There is a traumatic amputation of an arm or leg
- There is pulsing or steady bleeding from the wound
- Blood is pooling on the ground
- The overlying clothes are soaked with blood

If you see any of these examples during your visual blood sweep, apply a limb tourniquet over the uniform clearly proximal to the bleeding site(s). If the site of the life-threatening bleeding is not readily apparent, place the tourniquet “high and tight” on the injured limb and move the casualty to cover.

You may not really know if the hemorrhage is life-threatening until the Tactical Field Care phase when the wound can be exposed and evaluated. If you suspect it is life-threatening in Care Under Fire, treat it.

Remember, during CUF, the only medical intervention is applying a limb tourniquet to stop life-threatening bleeding from an extremity injury. Other wounds (like the neck, armpit, groin, or abdomen) are not treated during CUF. However, if the casualty is able, direct them to apply pressure to the wounds as self-aid. Airway and other issues are also not treated until the TFC phase.

The number one medical priority in CUF is early control of life-threatening external hemorrhage. Casualties with injuries to large central blood vessels (like the femoral artery, the axillary artery, or the carotid artery) can bleed to death in as little as 3 minutes. The faster you apply a tourniquet, the better the outcome and the less chance of shock and death.

A tourniquet is a constricting band placed around an arm or leg to stop bleeding. It is at least 2” wide (or wider, as the extra width reduces tissue damage) and can be applied quickly to stop life-threatening extremity bleeding.

Do not put a tourniquet directly over the knee or elbow or over a holster or cargo pocket that contains bulky items. It should be placed high and tight during CUF, and the time of application should not be documented until the Tactical Field Care phase. Some tourniquets use a windlass device to tighten, while others use a ratchet device, but both can be effective.

All personnel on combat missions should have a CoTCCC-recommended tourniquet readily available in a standard location on their battle gear and be trained in its use. Casualties should be able to easily and quickly reach and apply their own tourniquet. Tourniquets should NEVER be at the bottom of the pack. Always use the casualty’s tourniquet from their own JFAK first.

Always have more than one option available for tourniquet use in CUF. It is your responsibility as a CPP to ensure that you have multiple equipment sources and options for lifesaving interventions.

Casualties may need to apply tourniquets using a one-handed technique when applying self-aid for bleeding from an injury to the upper arm or forearm. Tourniquets typically come packaged in a looped configuration, which is necessary for one-handed application. Many units require their members to remove them from their original package and confirm this before deploying, as there is no time on the battlefield to ensure the tourniquet is properly looped before use.

The one-handed technique can be used with any of the CoTCCC-approved tourniquets, and we’ll concentrate on the windlass- and ratchet-type devices.

These next two videos will introduce you to the steps of applying one of these tourniquets to yourself, beginning with the windlass version.

# ONE-HANDED WINDLASS TOURNIQUET APPLICATION

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Now let’s take a look at the ratchet-type device using the one-handed technique.

# ONE-HANDED RATCHET TOURNIQUET APPLICATION

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Exercise extreme caution in treating and moving a casualty in Care Under Fire to avoid placing additional personnel at risk.

Upon approaching the casualty, quickly perform a visual blood sweep, looking for major bleeding. A two-handed tourniquet application is used when responding to a casualty that is unresponsive and/or unable to move in Care Under Fire. If present, apply a hasty tourniquet high and tight on the injured extremity and get the casualty and yourself to cover as quickly as possible.

When helping the casualty, be sure to use the tourniquet from the casualty’s JFAK first.

Two-handed tourniquets can be self-applied to the lower extremity but can also be applied by a responder to any extremity if the casualty is unable to do so for themselves.

This two-handed technique can be used with any of the CoTCCC-recommended tourniquets. The next two videos will demonstrate the windlass- and ratchet-type devices.

# TWO-HANDED WINDLASS TOURNIQUET APPLICATION

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Now let’s take a look at the ratchet-type device using the two-handed technique.

# TWO-HANDED RATCHET TOURNIQUET APPLICATION

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The following skill cards will help you practice the following skills:

#

Skill Card: One-Handed (Windlass) Tourniquet Application (CUF)
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Skill Card: One-Handed (Ratchet) Tourniquet Application (CUF)
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Skill Card: Two-Handed (Windlass) Tourniquet Application (CUF)
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Skill Card: Two-Handed (Ratchet) Tourniquet Application (CUF)
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It is critical to develop a plan to move the casualty (IAW unit SOPs). From the point of injury, you must move the casualty to the closest position of cover, and afterward, you may need to move them to another position of relative safety.

Once a tourniquet has been applied, the next priority is to get the casualty to the nearest cover and out of effective enemy fire/threat. Carries and drags will enable responders to do this as quickly as possible, hopefully without causing further harm to the casualty. Of note, at this phase of care, the tactical situation does not allow for spinal injury prevention measures.

A variety of effective carries can be used depending on the casualty’s level of consciousness, the enemy threat level, terrain issues, or other considerations. Each of them has some advantages, as well as some potential disadvantages.

Examples of one-person drag/carries include:

- Support Carry: can only be used with a conscious casualty
- Kit or Arm Drag: effective when moving down stairs but is not efficient for longer distances
- Pack-Strap Carry: best option when traveling with unconscious casualty over moderate distances
- Neck Drag: helps limit exposure from enemy fire based on the low profile of the rescuer.

In general, an advantage of one-person drags/carries is that only one rescuer is exposed to enemy fire, but they have the disadvantage of being difficult to perform, taking longer than two-person options, not allowing the rescuer to immediately engage with the enemy, and causing the rescuer to tire quickly.

This video will demonstrate some of the one-person drags and carries.

# ONE-PERSON CASUALTY DRAG / CARRY

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Several effective two-person drags and carries can be used, and which one you utilize will depend on the situation.

Some examples include:

- Two-Person Supporting Carry: a casualty is carried between two rescuers; can be used for conscious and unconscious casualties
- Kit or Arm Drag: allows the rescuers to maintain a “weapons up” posture while executing the drag
- Fore/Aft Carry: both rescuers move forward in unison.

Two-person carries may be useful in situations where drags do not work well and are quicker than most one-person carries, but they cause the rescuers to have a higher silhouette than most drags and are hard to accomplish with the added weight of rescuers' and/or the casualty’s equipment.

This video will demonstrate some of the two-person drags and carries.

# TWO-PERSON CASUALTY DRAG / CARRY

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The following skill cards will help you practice the following skills:

Skill Card: One-Person Drag/Carry (Kit or Arm Drag)
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Skill Card: Two-Person Drag/Carry (Kit or Arm Drag)
READ FULL PDF

Care Under Fire is the care rendered by first responders while still under effective hostile fire and is characterized by making medical and tactical decisions rapidly based on an understanding of the threats and the environment.

Returning fire to suppress the enemy, taking cover, and gaining fire superiority are the initial priorities for all personnel in Care Under Fire. The best medicine on the battlefield is fire superiority!

As established by the TCCC Guidelines, treatment priorities are to extricate casualties from burning vehicles or buildings and stop life-threatening hemorrhage through the use of limb tourniquets, if tactically feasible.

If you can do only ONE thing for the casualty, identify and stop life-threatening bleeding, and keep them from bleeding to death by using a CoTCCC-recommended tourniquet.

Once a tourniquet has been applied, the priority is to get the casualty to the nearest cover and out of effective enemy fire/threat. Carries and drags will enable responders to do this as quickly as possible without causing further harm to the casualty.

To close out this module, check your learning with the questions below (answers under the image).

# Answers

### What is Care Under Fire / Threat?

- Care Under Fire is the care given by the first responder at the scene of the injury while they and the casualty are still under effective hostile fire or near the threat.

### What are the signs of life-threatening bleeding?

- Bright red blood is pooling on the ground
- The overlying clothes are soaked with blood
- There is a traumatic AMPUTATION of an arm or leg
- There is pulsatile (pulsing) or steady bleeding from the wound

### How long does it take to bleed to death from a complete femoral artery and vein disruption?

- 3 minutes or less

### What are advantages and disadvantages of one-person drags?

- Advantages: only one rescuer is exposed to enemy fire.
- Disadvantages: they are difficult to perform and can cause the rescuer to tire quickly.

### What are advantages and disadvantages of two-person carries?

- Advantages: they are useful in situations where drags do not work well and are quicker than most one-person carries.
- Disadvantages: they cause the rescuers to have a higher silhouette than most drags, and are hard to accomplish with the added weight of rescuers' and/or the casualty’s equipment.

Throughout the course, you’ll note several references, but keep in mind that the TCCC Guidelines are the core guidance for assessing and treating casualties in a TCCC setting, as well as the emphasis for training. Likewise, the Prehospital Trauma Life Support (PHTLS), Military Edition teaches and reinforces the principles of rapidly assessing a trauma patient using an orderly approach.