Tactical Combat Casualty Care - TCCC, how to take care of wounded in the field

Facing many dangers and harsh environments, members of our armed forces put their lives at risk to protect our sovereignty and freedom. Battlefield is a hostile and hardly predictable environment, in which death and injuries are a scary part of everyday life.

In such an environment, you can not overestimate how important a quick and effective medical aid is. To help us understand and achieve that effectiveness comes a Tactical Combat Casualty Care course, or TCCC course for short. In this blog post we will take a look at its history and how important it is, we will also see what essential skills it teaches to soldiers and combat lifesavers.

To understand TCCC - history, how it came to existence, basic principles, and what does it have in common with “Blackhawk down”

In the nineties of the twentieth century, preparing combat medics was based on purely civilian materials and protocols which were effective for civilian use, on the types of injuries which occur the most in the civilian world. It will not be anything new, if we tell you that they were not so effective in the tactical environment, where types of wounds differ vastly from what you can get in a car crash or workplace accident, to not say anything about how dangerous the environment was or how long one would need for a proper medical team to arrive and evacuate the wounded.

The “most popular” types of wounds in civilian environment seemed to nearly not occur in tactical environment in comparison to numbers of gunshot wounds, chest wounds, shrapnel cuts, or blast damage. Even the medical equipment designed for civilian emergency units seemed lacking in such a high-danger environment.

A moment that opened the eyes for the United States armed forces was things happening during the accidents immortalized in the “Blackhawk down” film when United States forces made mostly of special forces operators suffered heavy wounds and many losses during what was supposed to be a quick mission.

To not cite the film, about which there goes the saying that if you watch it a thousand times you already know TCCC, we will end about it there, and move to North America, where Naval Special Warfare Command started work on a project called Tactical Combat Casualty Care, TCCC, based on information gathered from personnel that participated in this operation.

After three years and passing the project to Special Operations Command, in 1996 “Military Medicine Supplement” came into existence, it consisted of information and protocols to follow when taking care of wounded in a tactical environment. It was also the first time when a Tactical Combat Casualty Care term was first officially used.

What are the main differences TCCC made - saving lives during the fight

The most important information the TCCC committee got their hands on, was a report about number of each specific type of wounds that were inflicted during this operation, and many others. This allowed them to make a list of most lethal types of wounds that can be treated in the field, including the maximum time in which they have to be patched. Thet found out, that about 60% of wounds are bleedings from extremities, pneumothorax makes 33% and 6% are airways obstructions. All the other types of wounds made only about 1% of deadly cases.

The care for the wounded in TCCC is divided into three stages:

• Care Under Fire (CUF) - consists mostly of self aid, when group is still engaged;
• Tactical Field Care - when we are not under fire but still not yet in a safe spot;
• Tactical Evacuation Care - when we are giving the wounded off to the specialized medical teams for extraction.

Training lifesavers according to TCCC - how to protect yourself and wounded; Why every soldier is first a rifleman…

During marches, routine patrols, raids, or many other military activities we can get under fire from different types of weapons. The first reaction that every soldier has is to return fire and seek cover, and that is a very good reaction. But what if we get hit? What if one of our friends got hit and calls for help? That is when TCCC and its teachings come into play.

The first act - Care Under Fire

At this moment, the wounded person should focus on self-aid and returning fire. If you get hit and are still able to move and shoot, do it. Return fire and seek cover, it will not only offer you more protection but may also shorten the time that you and your team stay in contact, resulting in shortening the time before you can receive proper medical aid.

If the wounded person is unconscious, then after suppressing the enemy with fire, another person can drag her behind the cover and render the first medical actions. We are talking about applying wounded person tourniquets on her bleeding extremities. If the wounded is conscious, he can do it himself if such wounds exist.

We need to remember that all this takes place during the first minutes of contact, when we are still actively engaged in a firefight with the enemy, and as small number of people as possible should be engaged in life-saving. Focusing on neutralizing the threat will render the area safe faster, allow for more efficient medical aid, reduce the risk of getting more wounds, and allow for more freedom of movement.

Actions to be taken in this phase can be made into a simple list of organized steps:

1. Return fire and find cover;
2. Tell the wounded or demand from him to return fire;
3. Tell the wounded to move behind cover and to start applying self-aid, if not possible move the wounded behind cover;
4. Try to protect the wounded from getting more wounds;
5. The wounded should be evacuated from burning vehicles or buildings and moved to a relatively safe spot. Do whatever you need to stop them from burning;
6. Stop life-threatening bleeding if it is tactically possible:
• Tell the wounded to apply a tourniquet to bleeding extremities;
• Use CoTCCC recommended tourniquet to stop bleeding from extremities;
• Apply a tourniquet over the uniform above the wound. If the bleeding spot isn’t visible at first glance, apply a tourniquet “high and tight” on the wounded extremity and move the wounded behind the cover.
7. Secure airways, if not necessary, delay till the second phase.

The second act - Tactical Field Care

We move to this part when our immediate area is secure and we are safe enough to conduct further life-saving activities. All actions from now on should be done by trained personnel (TCCC-certified soldiers, combat lifesavers, medics, etc.), while still in the tactical environment. Activities now are done according to the MARCH protocol:

• Massive hemorrhage - We apply tourniquets and hemostatic dressings to stop life-threatening bleeding;
• Airways - We check the patient's airways for obstructions if he breathes, and if necessary secure his airways;
• Respiration - We dress chest wounds and check the patient’s chest for signs of pneumothorax, which we treat if the need arises;
• Circulation - We check the patient's circulation and consciousness against the AVPU scale. We do that by checking his pulse on the neck and extremities (the one without a tourniquet applied), checking warmth, wetness, and stickiness of sweat on the patient's belly and forehead with the inner part of our arms to check for shock;
• Hypothermia - at this time we secure the wounded from losing heat. We do it always, even if it is hot outside;

After we finish all those activities we go to the unwritten E, meaning “Everything Else” where we check dressings and tourniquets, monitor parameters, take care of smaller wounds, burns, and fractures, and check for head and brain damage.

The final act - Tactical Evacuation Care

After completing all the steps included in MARCH protocol we should try to evacuate our wounded as soon as possible. As we may be waiting for a medical evacuation for many hours or even a few days depending on our location, danger, weather, and many other factors, it is very important to monitor patient’s parameters and applied dressings.

All applied substances and dressings, wound mechanisms, and injuries should be noted on the patient's TCCC card in the proper places. If we lack this card (well, actually, if our patient lacks this card) or we are on the spot when he is evacuated, we should utilize MIST report to quickly relay the most important information about his state.

MIST report consists of these parts:

• Mechanism - the wounding mechanism, what resulted in him getting that wound, for example machine gun fire, mortar round, falling from height;
• Injury - Injuries taken like chest shot, amputated left arm, open fracture of right leg;
• Symptoms - patient's life parameters including his consciousness level according to AVPU scale, pulse, breathing, if possible blood pressure and oxidation, state of airways, pain, bleeding spots;
• Treatment given - what treatment we applied on wounded. We tell about all dressings, tourniquets, what meds were given including dosage.

Evolution of TCCC - why one should always seek to update and refresh his knowledge and skills

Lifesaving, and especially its tactical branch, is always evolving because new ways to poke holes into people get developed every day. The CoTCCC is always gathering information like the number of each type of wounds taken, their mechanism, how effective each recommended medical gear is, and even ideas to further enhance protocols or equipment from active duty operators, soldiers, medical crews, and doctors and thoroughly analyses them.

The result of that is a quarterly update of TCCC protocols and recommended equipment list. Such frequent updates increase the effectiveness of combat lifesavers and increased survivability on the battlefield. Thanks to the ongoing rush after updating their knowledge and getting more effective, modern medical personnel and combat lifesavers can offer highly effective help to the injured on the field.

Since the moment TCCC saw daylight and was pushed to the United States armed forces, we could observe a high decline in the number of deaths that could have been avoided. When during World War II 19% of such cases resulted in death, way later during Vietnam War 15%, even though medicine went a really long way since World War II, only after TCCC came in during the war in Iraq and Afghanistan, did these numbers drop to 9.4%.

The photo used in the material comes from the Wintertide battlefield medical aid competition.