Introduction to Tactical Combat Casualty Care, by W.H.

This is an introduction to Tactical Combat Casualty Care (TCCC), which is the medical training that U.S. troops are currently taught to save lives on the battlefield. TCCC is the result of collaboration between U.S. Special Operations Command, trauma doctors, and emergency medical personnel to address the shortcoming in combat medicine at the start, and actually well into the current Wars On Terror. It is the combination of good medicine with good tactics. It incorporates some procedures that are proven to save lives but in the past 75 years were shunned in the medical community. TCCC has proven to reduce the number of preventable deaths on the battlefield. The 75th Ranger Regiment had all of its troops and doctors train in TCCC. Their percentage of preventable deaths on the battlefield dropped to 3%, compared to the average of U.S. combat troops, which is 24%. Also note, the mindset for these procedures are not to necessarily save someone’s life but to prevent them from dying long enough to receive hospital level care. This is a very basic introduction. I am not certified in any medical care beyond TCCC, but I have seen and done these procedures on live patients, and they do work, when properly applied. The references listed on the bottom of the article have much more detail and information, as well as great videos and pictures, that help illustrate the topics covered in this post.

I will briefly describe the five main wound areas that need to be addressed and then the equipment needed to treat each wound. Nearly all of the equipment described can be bought easily online. The acronym MARCH can be used to remember the order of treatment, descending in order of importance.

Massive Hemorrhage

Airway

Respiration

Circulation

Head/Hypothermia

Massive hemorrhage (or bleeding)

This is the number one preventable killer on the battlefield. It is caused by a penetration to a major blood vessel or a complete or partial amputation. Any bleeding that is bright red, squirting, or heavy is considered massive hemorrhage and needs to be treated immediately. A major bleeder can kill the casualty within minutes; therefore, prompt treatment is essential. There are two treatments for a massive hemorrhage– tourniquets and wound packing.

The tourniquet is an essential tool for battlefield medicine, which has made a huge comeback in the recent wars. A tourniquet is used to treat a massive hemorrhage on a limb. They are fast, cheap, and extremely effective at stopping bleeding, if applied properly. There are many different types of tourniquets easily available for purchase on the Internet, but they all work roughly the same way. The tourniquet is placed high up on the affected limb, and the windlass is tightened until the bleeding stops. “High and Tight” is the easy way to remember. If placed too low on the limb, the pressure generated on the blood vessel won’t be high enough to stop bleeding; likewise, if it is too loosely applied, it won’t be effective. A number of deaths from the War on Terror were attributed to tourniquets being applied too loosely, where if applied properly, the bleeding could have been controlled and the casualty saved. It is worthy to note that having a tourniquet properly applied is VERY uncomfortable. Patients will plead and beg, or even try to loosen the tourniquet themselves, but under no circumstance should a tourniquet be removed by anyone other than a trained medical professional.

Tourniquets are now required to be carried by every soldier in his kit and be easily accessible, as it is a piece of life-saving equipment. During WWII and the Vietnam War, tourniquets were believed to be very dangerous to apply, and it was believed that it condemned the patient to loose that limb. Nowadays, they are saving countless of lives, as the dangers once associated with them have been tested as false. Sadly, movies and TV shows shape much of the public’s perception of trauma medicine. After the Boston bombings, many good Samaritans jumped in and used makeshift tourniquets to try and stop the bleeding from amputations caused by the explosions; however, none of these makeshift tourniquets were successful in stopping hemorrhage. Please don’t think that when the time comes, you can ripe your shirt off, put a stick through it, twist it a couple of times, and save someone’s life. It is my humble opinion that every household should have at least one tourniquet (preferably more) and know how to use them. I was issued 4 SOF-T tourniquets, so I have one in my at-home trauma bag, one in the bag I take to work, one on my kit, and one in reserve.

The second way to treat a major hemorrhage is wound packing. This is done on any major bleeder, not on a limb. While more time intensive than applying a tourniquet, wound packing can be just as effective at stopping bleeding. The idea behind wound packing is to first apply direct pressure proximally (closer to the heart) to the blood vessel against a bone. This will ensure that the immediate blood flow stops. If the wound is deep or on the trunk of the casualty, place gauze or a dressing as deep into the wound as possible. This will maximize the clotting effect. Also, once a dressing is soaked through with blood, it is imperative to leave it in place in the wound. If removed, it will remove the clot you are trying to form. Pack the entire wound with gauze, ideally placing it towards the head as you pack. Once the entire cavity has been packed, it is wrapped with another bandage to secure it in place. If done right, the pressure from the packing will slow down the bleeding enough for the platelets to start to clot, which will in essence seal off the blood vessel from further blood lose.

A note on Quikclot. It has undergone a couple of different variations, but the current product on the market is called Combat Gauze, which is a bandage impregnated with a compound that speeds up the clotting process. It is not a miracle cure-all product, but it does lead to a much more robust clot, which is more durable if the patient has to be moved. Additionally, Quikclot makes a Silver addition, which has a silver compound in the bandage that helps prevent infection. This could be very helpful in a survival situation in which doctor level care may be much longer away. The Israeli bandage is also another useful bandage to secure the dressings, once they have been placed in the wound. Like tourniquets, Quikclot and other bandages can be easily and cheaply purchased online, but be aware that the Quikclot has a shelf life, where gauze and other bulky dressings do not.

Airway

The second killer on the battlefield, which like bleeding can be controlled, is a blocked or restricted airway. There are some procedural differences between civilian and combat medicine. (Remember the ABCs, in which airway is treated first in civilian emergency medicine?) This is because by the time emergency responders arrive on scene, a massive hemorrhage has more than likely already killed the patient (in as little as 1-3 minutes). In tactical medicine, the number one killer is massive hemorrhage, followed by a blocked airway, and that is why it is treated in that order. Simply put, if the patient cannot breathe, he will expire in roughly four minutes. If a patient can talk, cry, laugh, or scream, they have a clear airway. If a patient is unconscious, it is easy for a patient to choke on his or her own tongue. When consciousness is lost, the tongue relaxes and, being a large muscle, can fall back and block the esophagus. The way to treat a blocked airway is an easy procedure called a nasopharyngeal (NPA), or in layman’s terms it’s often called “a nose hose”. It is simply a flexible rubber hose that is inserted into a patient’s nose to open the airway from the nostril to the back of the throat. When inserting a nose hose, push the hose straight back towards the spine, not up towards the bridge of the nose, as the nasal cavity goes straight back. It is standard TCCC procedure for any unconscious patient to automatically receive a nose hose. A nose hose can be purchased online for roughly $7. [HJL Adds: Rather than a $7 single NPA, you should have a kit of different sizes] After inserting a nose hose, make sure to look inside the patient’s mouth for any obvious obstructions. When checking the airway for obstruction, take care not to place your fingers inside the patient’s mouth, as the patient can seize and bite down without warning. Lastly, if the situation applies, consider rolling the patient onto his or her side, as this will help keep the airway clear of any fluids, such as vomit or blood, as well as the patient’s own tongue.

Respiration

After massive hemorrhage and airway have been addressed, the patient’s respiration needs to be checked. This is done by removing any body armor, kit, and outer clothes, and then looking for an equal rise and fall of the chest, listening for breathing, and feeling the chest rise. The risk to respiration is a pneumothorax. Simply put, this is caused by a penetration to the chest cavity that lets air into the pleural space– the area surrounded by the rib cage that protects the lungs and heart. This air bubble puts pressure on the lungs and heart– a condition that can be fatal, if left untreated. It will start out with shortness of breath, labored breathing, and can lead to the patient feeling an impeding sense of doom, unconsciousness, and death. The fancy medical term for this is “progressive respiratory distress”. The treatment for pneumothorax is needle decompression. This involves sticking a large gauge needle (14 gauge and 3.25 inches long) into the patient’s chest to relieve the pressure. While this sounds dangerous, if done right, it can and will save lives. The injection site for the needle is two to three finger widths below the center of the clavicle bone on the affected side of the patient. As the needle to do this is not easily available, I will not go into great detail. If there is any wound to the torso (above the belly button up to the neck and 360 degrees around the body), immediately seal the torso wound by placing your hand over it, and then sealing the hole, preferably with a medical chest seal, but in a pinch, duct tape and any airtight wrapper will do. If a gunshot wound is suspected, check very carefully for an exit wound, and again seal the wound to prevent air from entering the chest cavity.

Circulation

The TCCC procedure to address circulation in the MARCH sequence is to check the patient for shock. While there are many different types of shock, an easy definition for non-medical professionals is the inability of the body to transfer blood to its tissue (also known as profusion). In the case of traumatic injury, this is usually due to blood lose and the change in hormones following a traumatic event. As the body comes down from its amped up state, immediately following an injury, it realizes that it cannot keep up its current state and begins to shut off blood flow to the outer, less essential areas. However, a patient can suffer shock without sustaining a traumatic injury, usually after a person witnesses a horrific event. One of the easiest and most timely ways to check for shock is to check the patient’s radial (wrist) pulse. If there is a radial pulse, the body is still pushing blood to the hands. If no radial pulse is present, it is an indicator the body is no longer pushing blood to the hands in order to keep it for vital bodily functions and is going into shock. To prevent shock, timely treatment of massive hemorrhage is critical, as it reduces the amount of blood lose. Another way to help a patient suffering from shock it to elevate their feet, unless there is any indication that the patient has received any wound that could cause a spinal injury, in which case you DO NOT want to elevate their feet as this could paralyze them. My wife who is a trained EMT says that if there is any blood on the patient, EMTs would not risk paralyzing them by raising their feet. Likewise, it is not incorporated into TCCC, yet it remains a viable option in some instances. Lastly, getting fluids back into the patient as quickly as possible is a way to prevent shock.

Head/Hypothermia

Head injuries are a common occurrence on the battlefield, especially with the proliferation of Improvised Explosive Devices. While there is not much that you can do for yourself or your buddy on the battlefield, it is an important to pass on any information regarding signs of head injury, or Traumatic Brain Injury (TBI) to advanced medical care personnel. The signs and symptoms for a TBI include altered mental state, “raccoon eye” shaped bruises around the eyes, clearish yellow fluid leaking from the ears, mismatched pupil size, and any bumps or deformation in the skull. To check for TBI, check the patient for any of these signs.

Hypothermia can be a problem for wounded patients, as any blood loss or injury can diminish the body’s ability to retain heat. Even in a very warm climate, a patient can succumb to hypothermia. Anyone who has ever field dressed an animal knows how hot the internal organs are. To prevent this, after the patient is screened using the MARCH protocol, ensure that any body armor or clothes are put back on, and the patient is covered with a warming garment, whether it be a space blanket, wool blanket, sleeping bag, or in extreme cases, a buddy can use his body heat to re-warm the injured.

Everything Else

After the MARCH sequence has been completed, move on to everything else. The main preventable death injuries are covered in MARCH, but there are still other injuries, while not life threatening in minutes, that are still very important.

Superficial or non major hemorrhages: Any wound that does not strike a major blood vessel or organ is not immediately life threatening but can still look pretty scary. Injuries like this include cuts or wounds on the outside of the body, such as the forearms, outer legs, buttocks, and shoulders. Since the major blood vessels are located on the inside of the body and protected by bone and muscle, wounds to the outer parts of the body can be dealt with last, usually with a simply pressure dressing.

Eviscerations: While definitely very frightening and disgusting to witness, evisceration (abdominal wounds with the intestine hanging out) are not immediately life threatening. The old protocol was to keep any exposed intestines outside the body in a wet bag. However, the updated TCCC protocol is to gently place the intestines back into the wound and seal the wound up any way possible. While putting exposed internal organs back into the body does raise the risk of infection, it has been show that it is safer for the patient’s long-term health than leaving them outside the body.

Eye Injuries: While in any high-threat situation, eye protection should always be worn; still, the chance of eye injury exists. The best thing to do is to protect the eye but do not put the bandage directly on the eye; rather, allow the eye room to still move. While there are fancy eye patches out there, anything that will protect any further injury to the eye while still letting it move will do. To note, U.S. troops are issued battlefield antibiotics when deployed, in a survival situation these may not be immediately available, but with any injury, infection needs to be addressed, especially with eye trauma.

Some General Principles of TCCC:

  • Use a combination of good tactics and good medicine
  • Suppress effective enemy fire or immediate threats before attending to wounded personnel
  • Any completely or partially amputated limb receives a tourniquet
  • Treat major bleeders first (Care under Fire), then move injured person to cover, and begin Tactical Field Care (the rest of MARCH)
  • Before completing the next step in MARCH, check previous steps. For example, after placing a tourniquet on a major bleeder and moving the patient to cover, check the tourniquet before restoring airway, and then before checking the chest for wounds (Respiration) check that the tourniquet is still stopping the massive hemorrhage and the airway is still clear.

Building a Trauma Bag

I strongly recommend everyone have some sort of emergency medical bag. While first aid kits are great, they often times are severely lacking in medical supplies needed to stop life threatening injuries.

I attach my trauma bag, which is relatively small (3”x5”x8”) onto my larger medical bag. In a hostile environment survival situation, I can quickly remove my trauma bag from my med bag and attach it to my battle rattle.

My trauma bag consists of the following:

With a few differences (lack of decompression needle, the addition of the Quikclot Silver and Benadryl) this is what current U.S. soldiers carry in their Individual First Aid Kit, also know as a blow out kit. All of the items in my trauma kit can be purchased online for under $150. I strongly recommend, at the very least, a tourniquet, some bandages, and a chest seal.

Final Thoughts

In closing, while TCCC is primarily for a tactical battlefield environment, the principles of it can be applied to most traumatic injuries and can be very useful in a variety of survival situations. Whether it is surviving a mass shooting or bombing attack and giving the wounded precious minutes until professional medical responders can arrive, to rioting where medical services may be degraded, to a near total societal collapse, preventing death will always be useful. Like any survival skill, the knowledge, while important, is useless without practice. Every piece of medical gear listed in this article (with the exception of a decompression needle) is easily available for purchase online, and a very well-stocked trauma bag can be put together for around $150, but it is essential to practice the actual MARCH sequence and how to treat each wound. Thanks for reading. While I hope that no one ever has to use the skills mentioned in this article, I hope that when the need arises, the training, mindset, and equipment will be there to meet the challenge!

References:

National EMT TCCC homepage

A great resource for more info, videos of procedures, et cetera.

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