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.