During this module, we'll talk about medical equipment use during Tactical Combat Casualty Care. There are seven learning objectives starting with understanding how first aid kits are used in accordance with Service policy. In addition to identifying the contents of the individual Joint First Aid Kit (JFAK), combat lifesaver kits, and medic or corpsman aid bags, we’ll go over the use of those kits and the general maintenance and resupply procedures as defined by the Services.

CMC personnel will have to prepare for the mission tasks in a combat environment every time. As medical personnel, you must adapt to current information about your upcoming deployment.

Enemy tactics, techniques, and procedures (TTPs) constantly evolve, and should constantly be reevaluated, which in turn may change your medical equipment recommendations. Using threat-based planning (understanding available medical assets, intrinsic and local medical capabilities, and potential casualties, including evolving wound patterns) will provide medics with the information needed to organize their Aidbags more effectively. Knowing your support capabilities, such as theatre operations movement assets, will assist you in packing for your deployment. Given the differences in medical provider training and supplies within each Service, you may deploy with a different medical bag.    

The three main categories of kits you need to be familiar with are:

1. Joint First Aid Kit (JFAK); used by nonmedical personnel who are proficient in basic lifesaving TCCC skills. 
2. Combat Lifesaver (CLS) Bag; used by nonmedical personnel who are more advanced care to treat the most common causes of death on the battlefield and to recognize, prevent, and communicate with medical personnel.
3. Combat Medic/Corpsman (CMC) Aid Bags; used by medical personnel and are the first medical provider to care for the casualty in the prehospital environment and is expected to provide more advanced care requiring significantly more medical knowledge and skills. 

The contents of each of these kits are similar but reflect the TCCC scope of care of the responders intended to use the kit.  If there are equipment options approved by the Committee on Tactical Combat Casualty Care (CoTCCC), they must be used. For many, but not all, equipment categories, the CoTCCC has made evidence-based recommendations that will help ensure equipment failure is minimized. Some medical providers will have a preference for certain brands based on availability and history of use, but these should not be used in lieu of a CoTCCC-recommended product, if one is available.  Not all products are used the same way or have the same effectiveness.  

This lesson provides an opportunity to get a hands-on introduction to the kits and their contents. The equipment discussed supports the provision of TCCC per the current guidelines and enables the All Service Member, Combat Lifesaver, or Combat Medic/Corpsmen to address issues identified in Care Under Fire, Tactical Field Care, and TACEVAC Care using the MARCH PAWS approach.

Service members in today’s military carry a large array of equipment, and survival on the battlefield depends heavily on the ability to properly use that equipment. One piece of equipment that is critically important is the Joint First Aid Kit (JFAK).

Every piece of equipment chosen for the JFAK is evidence-based (based on lessons from years of war in Iraq and Afghanistan) and serves a distinct purpose for the individual Service member; knowing how to properly use what is in the JFAK can save a life.

Remember, when treating a casualty (providing combat life saver or medic-level aid), use the items that are in the casualty’s JFAK first. Each Service member’s JFAK should be reserved for self-aid whenever possible.

Every item that is in a JFAK supports provision of TCCC per the current guidelines. As massive hemorrhage, airway obstruction, and respiratory problems account for such a significant portion of preventable battlefield deaths, the JFAK equipment focuses on supporting treatments that address those concerns. Tourniquets, hemostatic dressing, and pressure bandages support massive hemorrhage treatment, nasopharyngeal airways address airway obstruction support, and chest seals and needles to decompress the chest address common respiratory concerns. Also, a Combat Wound Medication Pack should have been issued and added to the JFAK, and a DD Form 1380 is available for documentation purposes.

The Combat Lifesaver provides not only an additional level of medical training but also additional equipment. Some of the equipment in a CLS kit mirrors those items in the individual’s JFAK (tourniquets, dressings and bandages, chest seals, etc.). As you know, or will learn, casualties often suffer multiple injuries and require more equipment than they carry in their own JFAK, and the CLS kit supports that requirement.

In addition to the items previously highlighted, the CLS kit also typically has active and/or passive hypothermia prevention kits, additional supplies for wound care, as well as splints and cravats for fracture stabilization. There is more variability in the CLS kit than the JFAK, based on unit- and Service-specific considerations. 

As a reminder, when treating a casualty (providing combat lifesaver or medic-level aid), use the items that are in the casualty’s JFAK first. 

It is important to understand the potential operational impact of a heavy fighting load, which can be compounded by the weight of the CLS bag (or the Combat Medic/Corpsman aid bag). This must be considered when packing medical equipment and every effort made to reduce excess weight as much as possible without compromising casualty care.

The combat medic/corpsman aid bag has equipment similar to that in the CLS bag but provides an additional quantity of TCCC lifesaving equipment to support the care of multiple casualties. The enhanced skill set of the combat medic/corpsman also warrants additional medical equipment not found in the CLS bag to support a broader scope of care.

For example, the CMC aid bag contains junctional tourniquets for massive hemorrhage control, advance airways and cricothyroidotomy kits for airway management, and intravenous and intraosseous access supplies, IV fluids, blood products, and medications to address circulation issues and shock, to name a few. 

As with the CLS kits, combat medic/corpsman aid bags do not follow a specified packing list but rather are tailored based upon Service-specific policies, unit SOPs, and mission-specific planning considerations. The image below is not intended to be a comprehensive listing of all equipment, but rather highlights the varying equipment requirements of the kits needed to support the respective scopes of care of the different TCCC practitioners. 

You can see from this fairly extensive list of potential equipment and supplies, the size and weight of the aid bag can easily exceed the capacity of any one warfighter, and consideration should be given to cross-leveling equipment and supplies among other members of the unit. For example, additional IV fluids, dressings, etc. can be carried by teammates to make the load more manageable. 

Throughout this course, you will be learning about the details of most of this equipment. Identifying which items have CoTCCC-approved options, specific information about the actual materials, and describing how they are used is part of each course module. But an introduction to key equipment items might help set the stage.

The MARCH PAWS concept offers an organized approach to familiarizing you with basic TCCC equipment. We won’t be going over how the kits are organized or packed, but a general concept that has been highlighted by medics with deployment experience is to organize the equipment in such a way that items needed early in a casualty treatment scenario are very accessible, and grouping items that are likely to be used together into smaller packages within the main kit (like IV start kits with the IV fluids) helps increase efficiencies and probably improves casualty outcomes.

Lessons learned in previous conflicts remain true; hemorrhage is the number one killer in combat.

With massive hemorrhage accounting for the largest number of preventable deaths on the battlefield, the equipment to support bleeding control is found in almost all kits. Key items are highlighted below. CoTCCC-recommended tourniquets are used to control massive or severe hemorrhage (bleeding) of an extremity (arms and legs). This is the most important lifesaving item in the JFAK and should be kept easily accessible and ready for use.   

CoTCCC-recommended hemostatic dressings are called for when severe bleeding is observed from a wound in an area where a tourniquet cannot be used (groin, neck, axillary wounds) or when a wound is not severe enough to warrant a tourniquet. 

Emergency bandages or trauma dressings are elastic bandages that can be used alone or along with other forms of hemorrhage control (like hemostatic dressings) to enhance effectiveness in controlling bleeding by providing pressure to the wound.

For areas where you cannot place a tourniquet, such as the armpit or groin, a junctional tourniquet should be used. Injectable hemostatic agents are products that stop internal bleeding using nonabsorbable hemostatic sponges that expand and assist in bleeding control. The Wound Closure Device seals the edges of a wound closed to mitigate further blood loss until the wound can be surgically repaired,

You may encounter several airway adjuncts in your equipment kits. At all levels of kits, you are likely to find nasopharyngeal airways with lubricants used to keep the airway open by keeping the tongue from occluding the airway.

With higher-level kits, you may find Bag Valve Masks as well as more invasive airway adjuncts like extraglottic airways and cricothyroidotomy kits. These products establish an advanced airway without the use of intubation equipment. Some of the extraglottic products used are the i-gel®, Combitube, LMA, and King LT. This will all be covered in the airway module.

Surgical cricothyroidotomy kits can provide a surgical airway to a patient by creating a surgical opening in the cricothyroid membrane between the larynx and the cricoid cartilage. This should be a LAST RESORT procedure.

If your patient requires artificial respirations, the Bag Valve Mask (BVM) should be used. With or without oxygen, the BVM can be added to a medical kit in a compact state; check for any degrading of the material of the BVM before deployment.

You will find two other items to support respiration issues in most equipment sets: chest seals and needles for needle compressions. Chest seals, preferably vented, provide a self-adhering seal used for treating penetrating chest wounds. Although often referred to as a needle, the piece of equipment used to treat tension pneumothorax is actually a catheter-over-needle device, allowing the needle to be removed and the catheter to remain in place after use. 

Most of the equipment to support circulation and shock issues is found in the CMC kits, as opposed to the other kit levels. Replacing lost blood from hemorrhage requires access to administer fluids or blood products.

One common approach is intravenously, which requires several supplies – catheters, the equipment to start an IV, and a saline lock or IV tubing. Also, intraosseous access can provide a quick and reliable source of access to give medications, blood, or resuscitation fluids, and can be established at sternal, humeral, or tibial sites.  

Once access is established, blood products and/or fluids need to be given, and depending on the situation, your equipment will include those supplies, or you may need other equipment to draw blood from other members of the unit serving as a walking blood bank. 

If you are drawing blood from within the deployed forces, the EldonCard is a blood test kit that is transportable, compact, and easy to use. The test does not require refrigeration but does require clean drinking water. The kits are available for individual use, while a military kit can be used for larger groups. 

To prevent and/or help treat shock from internal hemorrhage, you may need to apply a pelvic compression device. 

And to help support clotting and reduce bleeding risk, you should have tranexamic acid (TXA) available.

At the CLS and CMC kit levels, you should find hypothermia prevention equipment. These may be hypothermia prevention kits (which provide active prevention) and/or various types of blankets (which are a passive form of preventing hypothermia).

Although there are no materials that specifically address head injury treatment, the AVPU assessment can be documented on the DD Form 1380, and CMC kits will include military acute concussion evaluation forms, called the MACE 2, which uses evidence-based guidelines for evaluating a traumatic brain injury.

The Combat Wound Medication Pack, or CWMP, is a prepackaged medication packet with drugs and dosages specifically chosen for use in combat casualty care and contains drugs for mild to moderate pain (meloxicam and acetaminophen) and an antibiotic specific for penetrating wounds (moxifloxacin). 

The CMC kits bring additional medications that support the management of pain that isn’t controlled by the CWMP and IV antibiotics that are used if the time and situation allow. There are multiple types of pain medications that allow for administration by mouth, intranasally, or by IV or IO access. 

Life-threatening wounds will have already been addressed using the equipment we’ve just talked about, but there are often other wounds to consider, like eye injuries, burns, or minor lacerations. Many of the kits contain compressed gauze or gauze rolls that are used to stop minor bleeding, cover wounds/burns, pack wounds, act as bulky material for pressure dressings, or pad pressure points in splinting. Also, the elastic bandages previously mentioned can be used to hold dressings or splints in place or can be applied more tightly to apply localized pressure on a wound.

Eye injuries are a common and unique injury, and for that reason, rigid eye shields, plastic, or metallic domed-shaped stiff shells provide protection of eye injuries without applying pressure to the eye and causing further damage. 

Broken bones are a common injury, and both CLS kits and CMC kits usually have equipment to splint those fractures. Malleable splints can be shaped to fit the needs of various fractures; however, they must be adequately bent to function properly. Cravats can be used to secure a splint or to create a sling or a swath. Femur fractures, or long bone fractures, can sometimes compromise the lower leg unless traction is applied during the splinting process, and some kits will come with traction splints to support that requirement.

Proper documentation is the responsibility of combat lifesavers as well as combat medics and corpsmen. The DD Form 1380 TCCC card is the DoD-approved form for official casualty care documentation of all assessments and treatment (as outlined by the TCCC guidelines) and must be completed on every casualty before handoff to another provider and/or evacuation to a medical treatment facility. It should be in each service member’s JFAK, preferably with the demographic information filled out in advance, but extra copies should be found in CLS and CMC kits, too. 

Although the 9-line MEDEVAC card is not a standard part of the Army CLS or Combat Medic Aid bag, some kits may also include a MEDEVAC request form or a blank template to assist in preparing and sending a 9-line MEDEVAC request. This is often dictated by unit procedures and based on the mission.

Pre-combat inspections (PCIs) or readiness checks are critical for every piece of equipment a service member carries and/or uses. For the JFAK, CLS bag, CMC aid bag, or unit/service-specific first aid kit, your life or your buddy’s life may depend on the readiness and serviceability of the contents. It is critical that you frequently inspect equipment before, during, and after all training events and combat missions. Resupply when needed.

For some items that don't require sterility or won't degrade with exposure to air, like tourniquets, it is appropriate to take them out of their packaging to save time when using them on the battlefield. With the CAT tourniquet, one of the more common limb tourniquets in the inventory, there is configuration option to optimize its one-handed use when supplying or resupplying your equipment kits. This video will review the steps you would take to configure a CAT tourniquet.

CAT QUICK LAUNCH 
CONFIGURATION VIDEO

Inventory Your Kits and Bags

Make sure all required and applicable equipment is in your Service-specific JFAKs, CLS Bags, and CMC Bag.

Seals and Wrappers

Items with broken or unsealed wrappers should be replaced. If an item was vacuum sealed tightly when issued and is no longer sealed upon inspection, it should be replaced.    

Check Expiration Dates

Medications and many medical-grade materials such as hemostatic dressings have an expiration date and lot number. Check all medications and medical-grade items for expiration date and replace if expired or the expiration date does not exceed your expected deployment timeframe. Generally, items such as tourniquets do not have an expiration date, but check to ensure the devices are approved by the DoD Committee on Tactical Combat Casualty Care, are serviceable, and reflect the current generation (have not been replaced with a newer model, etc.).

Sometimes, you may overtrain with equipment, and that can affect its function (like a windlass rod of a tourniquet that can crack and break with repeated use), so train on your equipment but obtain new supplies before deploying that are the same makes and models that you trained with.

Knowing your limitations will help you to provide the best medical care possible. Training on equipment will make you proficient in the task, but if you deploy with other products, then you may not understand the product when you really need to know it. For example, if you train with a CAT 7 tourniquet, then deploy with that tourniquet. Do not carry equipment that you do not know how to use or will not use.

Mass casualties can last for a small amount of time or span over a matter of days, so triage your equipment in order for it to last. Use your patient’s supplies first to preserve your supplies for others who are injured.

Cross-stock your equipment. Inspect your gear to make sure it is combat-ready. Tourniquets are notorious for breaking because of repeated use, so if you train with your equipment, make sure to replace or inspect the equipment before deployment to ensure it will not fail.    

Train with a heavier load to prepare for the rigors of combat. Understanding your terrain will also help you adjust to the physical requirements. A deployment to the mountains of Afghanistan is different from the flat deserts of Iraq, which means different preparation.

It is important to understand the potential operational impact of a heavy fighting load which can be compounded by the weight of the CLS bag (or the Combat Medic/Corpsman aid bag). This must be considered when packing medical equipment and every effort made to reduce excess weight as much as possible without compromising casualty care.

BEWARE OF UNAPPROVED EQUIPMENT!

Some items within the JFAK require specific recommendation from the CoTCCC. CoTCCC recommendations are based on scientific studies, evidence-based medicine, field-use testing, and lessons learned from the battlefield. Always check to ensure your kits are stocked only with CoTCCC-recommended/approved items and beware of unapproved equipment.

BEWARE OF FAKES!

There are fraudulent manufacturers around the world that produce fake, misleading, or substandard pieces of medical equipment, especially those used in the JFAK (tourniquets and hemostatic dressings).

CHECK UNIT-SPECIFIC EVACUATION EQUIPMENT!

Litters should be inspected for proper functioning and serviceability; litter straps should be checked for locking functions and placement; special evacuation equipment should be checked in accordance with manufacturers or unit guidelines/standards.

You should now be able to identify the basic equipment usually found in individual kits, or JFAKs, Combat Lifesaver kits, and Combat Medic/Corpsman bags, understanding that the needs of the medic/corpsman can vary from person to person. Likewise, you should be able to describe how the various kits support TCCC delivery following the MARCH PAWS treatment approach.

Knowing what to pack can be difficult even for the most experienced medical provider. Historical data can help you understand what to take and how much.

Ensure the integrity of your supplies is intact before deploying and resupply kits, as needed. Remember all your assets, such as additional military forces that will help you carry supplies, vehicles being used (both vehicles of opportunity and pre-set medical vehicles such as ambulances). 

It is vital to know your equipment, so you must train with the supplies you will use before deployment.    

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

Answers

What type of tourniquet found in the CMC Aid Bag is used to control massive hemorrhage in the axilla that is too proximal for effective limb tourniquet application? 

Junctional Tourniquet

When should you inspect your JFAK, CLS bag, CMC bag and other Service-specific medical kits? 

Before, during, and after all training events and missions.