Att_25_Combat_LifeSaver_Course_(CLS)_Guidelines.pdf

SUBCOURSE EDITION

IS0871 C

COMBAT LIFESAVER COURSE:

STUDENT SELF-STUDY

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ADMINISTRATIVE PROBLEMS

Questions of an administrative nature (such as missing pages in the subcourse booklet) should be addressed to your primary instructor (group leader). If you have questions of an administrative nature after you have completed the course, you may write or call the Army Institute for Professional Development (AIPD) at the following:

Address: Army Institute for Professional Development ATTN: ATIC-IPS (Student Services) U.S. Army Training Support Center Newport News, VA 23628-0001

Telephone: DSN 927-3335/3322

Commercial (757) 878-3335/3322

E-mail: sectiona@atsc.army.mil

CONTENT

Questions about the content of this subcourse should be directed to your primary instructor (group leader). If you still have questions or comments concerning course content, write or call the subject matter expert responsible for this edition of the subcourse, Mr. Donald Parsons.

Address: U.S. Army Medical Department Center and School Department of Combat Medic Training

ATTN: MCCS-AW

3151 W W White Road Fort Sam Houston, TX 78234-6100

Telephone: DSN 471-5235

Commercial (210) 221-5235

E-mail: Donald.Parsons@amedd.army.mil

CLARIFICATION OF TRAINING LITERATURE TERMINOLOGY

When used in this publication, words such as "he," "him," "his," and "men" are intended to include both the masculine and feminine genders unless specifically stated otherwise or when obvious in context.

This subcourse is approved for resident and correspondence course instruction. It reflects the current thought of the U.S. Army Medical Department Center and School and conforms to Department of the Army doctrine as closely as currently possible.

Development and progress render such doctrine subject to change.

The "C" edition of IS0871 is a major revision of the previous "B" edition. Copies of edition “B” should no longer be used. This subcourse may be reproduced locally as needed.

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COMBAT LIFESAVER COURSE: STUDENT SELF-STUDY

INTERSCHOOL SUBCOURSE 0871

U.S. Army Medical Department Center and School Fort Sam Houston, Texas

GENERAL

Interschool Subcourse 0871, Combat Lifesaver Course: Student Self-Study, contains information needed to pass the written, written performance, and performance examinations for combat lifesaver certification and recertification. All of the tasks contain important, lifesaving information.

Terminal objectives for this course are given below.

TASK: Tactically manage a casualty.

CONDITIONS: Given a casualty in a battlefield environment and a combat lifesaver medical equipment set.

STANDARDS: Applied the procedures given in this course so that the mission is not endangered and the risk of additional injury to the casualty is minimized.

TASK: Evaluate and treat a casualty.

CONDITIONS: Given a combat lifesaver medical equipment set and a casualty with one or more of the following problems: blocked airway, no respiration, bleeding from an extremity, amputation of an extremity, hypovolemic shock, or open chest wound.

STANDARDS: Performed needed procedures in accordance with the procedures given in this course and documented the treatment on a U.S. Field Medical Card or Tactical Combat Casualty Care Card, as appropriate.

TASK: Prepare and transmit a request for medical evacuation.

CONDITIONS: Given a writing instrument, a MEDEVAC worksheet, needed information, and a transmitting device.

STANDARDS: Prepared a MEDEVAC request in correct format and transmitted the request following the rules for proper transmission.

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TASK: Transport a casualty.

CONDITIONS: Given a casualty in need of evacuation, drag equipment (such as a

Dragon Harness or SLICK litter), a SKED litter, a Talon litter, materials for improvising a litter (if used), and assistant(s) (if needed).

STANDARDS: Prepared the SKED litter, Talon litter, improvised litter, or other equipment (if used) and evacuated the casualty using a drag, manual carry, or litter in accordance with the procedures given in this subcourse.

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TABLE OF CONTENTS

Page

GENERAL .... ...................................................................................................... ii

ADMINISTRATIVE INSTRUCTIONS .................................................................. v

GRADING AND CERTIFICATION ....................................................................... vi

Lesson 1 INTRODUCTION TO THE COMBAT LIFESAVER AND

TACTICAL COMBAT CASUALTY CARE ...................................... 1-1

Section I. The Role of the Combat Lifesaver ............................... 1-1 Section II. Tactical Combat Casualty Care ................................... 1-2 Exercises ...................................................................................... 1-9

Lesson 2 CARE UNDER FIRE ...................................................................... 2-1 Exercises ...................................................................................... 2-9

Lesson 3 TACTICAL FIELD CARE ............................................................... 3-1 Exercises ...................................................................................... 3-17

Lesson 4 CONTROLLING BLEEDING .......................................................... 4-1 Section I. Controlling Bleeding Without a Tourniquet ................... 4-1 Section II. Applying a Tourniquet .................................................. 4-10 Exercises ...................................................................................... 4-22

Lesson 5 OPENING AND MANAGING A CASUALTY'S AIRWAY ................ 5-1 Exercises ...................................................................................... 5-10

Lesson 6 TREATING PENETRATING CHEST TRAUMA ............................. 6-1 Section I. Treating an Open Chest Wound .................................. 6-1 Section II. Treating Tension Pneumothorax .................................. 6-6 Exercises ...................................................................................... 6-12

Lesson 7 INITIATING A FIELD MEDICAL CARD OR TCCC CARD ............. 7-1 Section I. U.S. Field Medical Card ............................................... 7-2 Section II. Tactical Combat Casualty Care Card ........................... 7-14 Exercises ....................................................................................... 7-19

Lesson 8 REQUESTING MEDICAL EVACUATION ...................................... 8-1 Exercises ....................................................................................... 8-15

Lesson 9 TACTICAL CASUALTY MOVEMENT ............................................ 9-1 Exercises ....................................................................................... 9-12

Lesson 10 EVACUATING A CASUALTY USING A LITTER ........................... 10-1 Exercises ....................................................................................... 10-12

Appendix A COMBAT LIFESAVER MEDICAL EQUIPMENT SET .................... A-1 Appendix B HAWES CARRY ............................................................................ B-1

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ADMINISTRATIVE INSTRUCTIONS

SUBCOURSE CONTENT

This subcourse contains ten lessons. Each lesson contains information needed to successfully perform one or more tasks that a combat lifesaver is required to perform.

SUPPLEMENTARY REQUIREMENTS

Materials Needed. You will be furnished with needed materials at the time you take the examinations for this subcourse. Successful completion of the comprehensive written (multiple-choice) examination, written performance (Tactical Combat Casualty Care Card and MEDEVAC request) examinations, and all performance (hands-on) examinations is required for successful completion of the Combat Lifesaver Course.

Supervisory Assistance. Study the information contained in this subcourse on your own before attending classroom instruction. When you take the performance (hands-

on) examinations, the evaluator will use checklists similar to those contained in this subcourse. Each written performance examination will require you to complete a form.

The comprehensive written examination will consist of multiple-choice items and will be closed-book and proctored. Reference materials other than those provided by the evaluator will not be permitted.

References. This subcourse contains all information needed to pass the written, written performance, and performance examinations. No supplementary references are needed. However, references for additional study are given with the lessons.

SUGGESTED STUDY PROCEDURES

After reading and studying the text assignment of a lesson, complete the lesson exercises at the end of the lesson. If possible, answer the exercises without referring back to the lesson text. After completing the exercises, check your answers with the answer key that follows the lesson exercises. For each exercise answered incorrectly, reread the subcourse material referenced and rework the exercise.

If the lesson exercises contain a performance exercise, practice performing the task (if possible) and have someone check your actions against the performance checklist.

When you take the actual performance examinations, an instructor will grade your performance using checklists similar to those contained in this subcourse. Keep practicing until you can score a GO on all steps.

The use of scenario training that allows the Combat Lifesaver student to perform in his full battle gear for performance testing is encouraged.

Complete each lesson before proceeding to the next.

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GRADING AND CERTIFICATION

You must score a minimum of 70 percent on the written (multiple-choice) examination and score a GO on each written performance and performance examination in order to pass this course. A NO-GO on any step of a performance checklist will result in a NO- GO for the entire checklist.

The written and written performance examinations will be proctored. You will not be allowed to use the subcourse or notes during the examination.

The primary instructor (or a designated assistant) will be responsible for grading the written, written performance, and performance examinations. Please consult your primary instructor or his designated assistant for any questions concerning retaking a failed examination (written, written performance, or performance). An examination may have more than one version. If so, an alternate version may be used for retesting.

A student who successfully completes the entire Combat Lifesaver Course (successfully completes all performance and written performance examinations and passes the comprehensive written examination) will receive 40 credit hours from the Army Institute for Professional Development (AIPD), Newport News, Virginia. There is no partial credit. AIPD will send a notice of completion to the primary instructor for each student who successfully completes the entire Combat Lifesaver Course.

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LESSON 1

INTRODUCTION TO THE COMBAT LIFESAVER AND

TACTICAL COMBAT CASUALTY CARE

TASK

Tactically manage a simulated casualty.

CONDITIONS

Given a written situation concerning tactical combat casualty care and possible responses.

STANDARDS

Select the correct response based upon instruction given in Subcourse IS0871.

REFERENCES

STP 21-1-SMCT, Soldier's Manual of Common Tasks: Skill Level 1.

FM 4-25.11, First Aid.

Prehospital Trauma Life Support Manual, sixth edition. Published by Mosby/Elsevier.

Section I. THE ROLE OF THE COMBAT LIFESAVER

1-1. ARMY BATTLE DOCTRINE

The Army battle doctrine was developed for a mobile and widely dispersed battlefield. The doctrine recognizes that battlefield constraints will limit the ability of trained medical personnel, including combat medics (Health Care Specialist, MOS 68W), to provide immediate, far-forward care. Therefore, a plan was developed to provide additional care to injured combat soldiers. The combat lifesaver is part of that plan.

1-2. PURPOSE OF THE COMBAT LIFESAVER

a. The combat lifesaver is a bridge between the self-aid/buddy-aid (first aid) training given all soldiers during basic training and the medical training given to the combat medic. The combat lifesaver is a nonmedical soldier who provides lifesaving measures as a secondary mission as his primary (combat) mission allows. The combat lifesaver may also assist the combat medic in providing care and preparing casualties for evacuation when the combat lifesaver has no combat duties to perform.

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b. Normally, one member of each squad, crew, or equivalent-sized unit will be trained as a combat lifesaver.

c. A major advantage of the combat lifesaver is that he will probably be nearby if a member of his squad or crew is injured. It may take a combat medic several minutes or longer to reach the casualty, especially if there are several other casualties and/or the medic is at another location. The combat lifesaver is trained to provide immediate care that can save a casualty's life, such as stopping severe bleeding and performing needle chest decompression for a casualty with tension pneumothorax.

1-3. COMBAT LIFESAVER'S AID BAG

a. The combat lifesaver carries a small aid bag (called a medical equipment set or MES) containing supplies for controlling bleeding, relieving tension pneumothorax, and performing other procedures. A listing of the supplies found in the aid bag at the time this subcourse was developed is given in Appendix A. For current information, check the U.S. Army Medical Materiel Agency (USAMMA) listing at http://www.usamma.army.mil/ on the Internet under DOD Unit Assemblages.

b. Some items must be replaced when their expiration date nears. Usually, the combat lifesaver's unit will perform the needed stock rotation. If the combat lifesaver maintains his own bag, he must replenish his supplies in accordance with his unit's standing operating procedure (SOP).

c. During combat, the combat lifesaver will need to be resupplied rapidly as his supplies can be quickly depleted. The combat lifesaver can obtain additional supplies from combat medics, from battalion aid stations or other nearby medical treatment facilities, and from ambulances evacuating casualties.

Section II. TACTICAL COMBAT CASUALTY CARE

1-4. BATTLEFIELD DEATHS

Around 90 percent of combat deaths occur on the battlefield before the casualties reach a medical treatment facility (MTF). Most of these deaths are inevitable (massive trauma, massive head injuries, and so forth). However, some conditions such as bleeding from a wound on an arm or leg, tension pneumothorax, and airway problems can be treated on the battlefield. This treatment can be the difference between being a combat death on the battlefield and a recovering soldier in an MTF.

It has been estimated that proper use of self-aid, buddy-aid, and combat lifesaver skills can reduce battlefield deaths by 15 to 18 percent. Figure 1-1 gives a breakdown of battlefield deaths in the Viet Nam conflict. Figure 1-2 shows a breakdown of preventable deaths in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Both figures indicate that extremity hemorrhage (severe bleeding from an arm or leg), tension pneumothorax, and airway obstruction continue to be the primary preventable causes of death in modern combat with extremity hemorrhage resulting in the most deaths.

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DEATHS DUE TO GROUND COMBAT

31 percent--Penetrating head trauma.

25 percent--Surgically uncorrectable torso trauma.

10 percent--Potentially surgically correctable trauma.

9 percent--Bleeding from wounds on the extremity.

7 percent--Mutilating blast trauma.

5 percent--Tension pneumothorax.

1 percent--Airway problems.

Less than 5 percent--Died of wounds (DOW) after evacuation to an MTF, mostly from infections and complications of shock.

NOTE: Numbers do not add up to 100 percent. Not all causes of death are listed.

Some deaths are due to multiple causes.

Figure 1-1. Breakdown of battlefield deaths (Viet Nam).

Figure 1-2. Primary injury site as a cause of death in the potentially preventable deaths (OIF/OEF).

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1-5. PHASES OF TACTICAL COMBAT CASUALTY CARE

Tactical combat casualty care (TCCC) can be divided into three phases. The first is care under fire, the second is tactical field care, and the third is tactical evacuation care.

a. Care Under Fire. In care under fire, you are under hostile fire and are very limited as to the care you can provide. Treatment consists primarily of using a tourniquet to stop life threatening bleeding from wounds on the extremities and moving the casualty to safety (see Lesson 2).

Remember, in combat, functioning as a combat lifesaver is your secondary mission. Your combat duties remain your primary mission. Your first priority while under fire is to return fire and kill the enemy. You should render care to injured soldiers only when such care does not endanger your primary mission.

b. Tactical Field Care. In tactical field care, you and the casualty are not under effective enemy fire and you are free to provide casualty care to the best of your ability.

However, the tactical situation can change and you could find yourself back in a care-under-fire situation.

(1) Tactical field care may be rendered by the combat lifesaver after the casualty has been moved to a safe location or when enemy fire has been suppressed (see Lesson 2).

(2) Tactical field care also refers to care rendered by the combat lifesaver when the casualty is discovered in a tactical field care situation. That is, the casualty was not in a care-under-fire situation to begin with (see Lesson 3).

(3) In tactical field care, available medical equipment and supplies are limited to that carried into the field by the combat lifesaver and individual soldiers.

c. Tactical Evacuation Care. In tactical evacuation care, the care is rendered while the casualty is being evacuated to a collection point or medical treatment facility (see Lesson 10).

(1) Casualty evacuation (CASEVAC) refers to the movement of casualties using nonmedical vehicles or aircraft. In CASEVAC, the combat lifesaver may travel with the casualty to provide care during transportation.

(2) Medical evacuation (MEDEVAC) refers to evacuating casualties using medical ground ambulances or medical air ambulances. Medical evacuation vehicles (ground and air) have medical personnel to care for casualties during evacuation.

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1-6. TERMINOLOGY

As you go through this subcourse, it will be helpful to know the meaning of certain terms. It is also recommended that you consult a medical dictionary for unfamiliar terms.

a. Casualty. The casualty is the soldier who is injured.

b. Rescuer. The term rescuer refers to another soldier who is attempting to aid the casualty (provide treatment and/or move the casualty to safety).

c. Self-Aid. Self-aid is the care (treatment) that the casualty gives to himself.

(Care given by another soldier is buddy-aid. Care given by medical personnel such as a combat medic is medical aid.)

d. Medical Treatment Facility. A medical treatment facility (MTF) is a facility established to provide medical and/or dental care. In combat, the battalion aid station (BAS) is a mobile medical treatment facility close to the front lines.

e. Collection Point. A collection point is a site to which combat casualties are delivered, usually by nonmedical means (CASEVAC). There, the casualties are transferred to medical vehicles (ground or air ambulances) and transported to an MTF

(MEDEVAC).

f. Extremity. The term extremity refers to one of the limbs.

(1) Upper extremity. Upper extremity refers to the arm (located between the shoulder and the elbow) and the forearm (located between the elbow and the wrist).

Often, the term "arm" is used to refer to the arm, forearm, and hand. The terms "upper arm" and "lower arm" are sometimes used to refer to the arm and forearm respectively.

(2) Lower extremity. Lower extremity refers to the thigh (located between the hip and the knee) and the leg (located between the knee and the ankle). Often, the term "leg" is used to refer to the thigh, leg, and foot. The terms "upper leg" and "lower leg" are sometimes used to refer to the thigh and leg respectively.

g. Hemorrhage. Hemorrhage is another word for bleeding. It usually refers to serious bleeding.

h. Dressing. The term "dressing" refers to the material that is placed directly over the wound. The dressing absorbs some of the blood and helps a clot to form. The clot "plugs" the wound to stop the bleeding. The dressing also protects the wound from additional contamination and injury.

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i. Bandage. A bandage is the material used to hold (secure) the dressing in place so the dressing will not slip and destroy the clot that is forming. The ends of the bandage are called the tails.

j. Field Dressing. The field dressing consists of a pad of sterile (germ-free) white dressing with a bandage (usually olive drab) already attached to the dressing pad (see figure 1-3). The field dressing is wrapped in paper which is then sealed in a plastic envelope. The field dressing is also called the field first aid dressing and the combat dressing. It is being replaced by the Emergency Bandage, but may still be encountered.

Figure 1-3. Field dressing.

k. Emergency Bandage. The Emergency Bandage® (figure 1-4) consists of a sterile white pad with an elastic tail and a pressure device used to apply continuous pressure to the wound. This bandage is also known as the "emergency trauma dressing," "emergency trauma bandage," "Israeli pressure dressing," and "Israeli bandage." It is replacing the field dressing in the soldier's individual first aid kit. Each soldier should have an Emergency Bandage in his Improved First Aid Kit (IFAK). You have two Emergency Bandages in your combat lifesaver aid bag.

Figure 1-4. Emergency Bandage in its pouch.

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l. Combat Gauze. Combat Gauze™ (figure 1-5) is also called the hemostatic bandage. It uses pressure and a chemical to help stop the bleeding. It is a component of the soldier's Improved First Aid Kit (IFAK). You have three Combat Gauze bandages in your combat lifesaver aid bag.

NOTE: A hemostatic agent is an agent that arrests the flow of blood.

Figure 1-5. Combat Gauze.

m. Tourniquet. A tourniquet is a device for compressing the blood vessels of an extremity in order to stop blood flow distal to the tourniquet band.

n. Combat Application Tourniquet. The Combat Application Tourniquet®

(CAT) is a device developed specifically to be used as a tourniquet. See figure 1-6. It is a component of the soldier's Improved First Aid Kit (IFAK). You have two in your combat lifesaver aid bag.

Figure 1-6. Example of a Combat Application Tourniquet.

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o. Combat Casualty Pill Pack. Each soldier may be issued a combat pill pack (see figure 1-7) containing pain medications and antibiotics to control infection prior to deployment on tactical missions.

Figure 1-7. Combat pill pack.

p. Improved First Aid Kit. The Improved First Aid Kit (IFAK) is the first aid kit carried by individual soldiers. Normally, the kit contains a Combat Application Tourniquet, an Emergency Bandage, Combat Gauze, a nasopharyngeal airway, a roll of 2-inch tape, and two pairs of examination gloves.

q. Combat Lifesaver Medical Equipment Set. The combat lifesaver medical equipment set (MES) is also called the combat lifesaver aid bag. It is carried by the combat lifesaver in combat. The contents of the MES are given in Appendix A.

r. Distal. Distal means away from the point of reference. In this lesson, the heart is the central point of reference. The hand is distal to the elbow because the hand is farther from the heart than is the elbow. (Follow the path of blood flow from the heart through the arteries as a guideline.) It is the opposite of proximal.

s. Proximal. Proximal means toward the point of reference (heart). The knee is proximal to the foot because the knee is closer to the heart (following blood flow) than is the foot. It is the opposite of distal.

t Artery. Arteries are blood vessels that carry blood away from the heart to the parts of the body.

u. Vein. Veins are blood vessels that carry blood from the parts of the body back to the heart.

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EXERCISES: LESSON 1

INSTRUCTIONS: Answer the following exercises by marking the letter of the response that best answers the question or best completes the sentence or by writing the answer in the space provided.

After you have answered all of the exercises, check your answers against the "Solutions to Lesson Exercises" at the end of the exercises. For each exercise answered incorrectly, reread the lesson material referenced.

1. Of the deaths that occur during ground combat, about what percent die before reaching a medical treatment facility?

a. 10 percent.

b. 50 percent.

c. 75 percent.

d. 90 percent.

2. Your unit is in ground combat. You see a soldier fall as though he has been shot.

Your primary duty is to:

a. Continue firing at the enemy.

b. Stop firing and go to the fallen soldier.

3. You are treating a casualty while under fire. Which of the following can you perform before moving the casualty to a place of safety?

a. Perform cardiopulmonary resuscitation (CPR).

b. Apply a tourniquet to control severe bleeding on a limb.

c. Perform needle chest decompression to relieve tension pneumothorax.

d. Administer the combat pill pack to control pain and infection.

e. None of the above.

4. Tactical combat casualty care has three phases. List the phases.

a. _______________________________________________________________

b. _______________________________________________________________

c. _______________________________________________________________

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5. A casualty is being transported to a collection point using a nonmedical vehicle.

Which of the following terms apply?

a. CASEVAC.

b. MEDEVAC.

6. What medical term means bleeding, usually severe?

7. A pad of material placed on the wound to absorb the blood is called the

_____________________ while the material used to keep the pad from slipping off the wound is called the _____________________________.

8. The wrist is ____________ to the elbow. The elbow is ____________ to the wrist.

a. Distal; proximal.

b. Proximal; distal.

9. Is the combat lifesaver considered to be a medical soldier?

a. Yes.

b. No.

10, What are the three most common medically preventable causes of death on the modern battlefield?

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11. Of the three preventable causes of death in exercise 10, which results in the most deaths?

Check your answers on the next page.

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SOLUTIONS TO EXERCISES: LESSON 1

1. d (para 1-4)

2. a (paras 1-2a, 1-5a box)

3. b (para 1-5a)

4. a. Care under fire.

b. Tactical field care.

c. Tactical evacuation care. (paras 1-5a, b, c)

5. a (para 1-5c(1))

6. Hemorrhage (para 1-6g)

7. Dressing; bandage (paras 1-6h, i)

8. a (paras 1-6r, s)

9. b (para 1-2a)

10. Extremity hemorrhage (severe bleeding from an arm or leg).

Tension pneumothorax.

Airway obstruction. (para 1-4, fig 1-1)

11. Extremity hemorrhage (severe bleeding from an arm or leg). (para 1-4, fig 1-1)

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LESSON 2

CARE UNDER FIRE

Tactically manage a simulated casualty in a care under fire situation.

CONDITIONS

Given a written situation concerning a casualty under combat conditions and possible responses.

STANDARDS

Select the correct response based upon instruction given in Subcourse IS0871.

REFERENCES

STP 21-1-SMCT, Soldier's Manual of Common Tasks: Skill Level 1.

2-1. INTRODUCTION

Care under fire is the first phase of tactical combat casualty care. In care under fire, you and the casualty are under hostile fire and you are very limited to the care you can provide. In fact, you may not be able to provide any care. Your combat duties remain your primary mission. Your first priority while under fire is to return fire. You should render care to injured soldiers only when such care does not endanger your primary (combat) mission.

2-2. ACTIONS UNDER FIRE

When you are under effective hostile fire and see a wounded soldier who is also under enemy fire, you should do the following.

a. Take cover and return fire.

b. Suppress enemy fire. Reducing enemy fire may be more important to the casualty's survival than any immediate treatment you can provide.

c. Try to keep the casualty from sustaining any additional wounds.

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d. Direct or expect the casualty to remain engaged as a combatant.

e. Try to determine if the casualty is alive.

f. If the casualty can function, direct him to move to cover, return fire, and administer self-aid.

g. If the soldier has suffered an amputation or has serious bleeding from an extremity, direct him to apply the Combat Application Tourniquet from his Improved First Aid Kit (IFAK) over his uniform and above the wound.

h. If the casualty is unable to return fire or move to safety and you cannot assist him, tell the casualty to “play dead.”

i. Communicate the situation to your unit leader.

2-3. ACTIONS BEFORE APPROACHING THE CASUALTY

If you determine that you can provide assistance to the casualty under enemy fire, take the following actions before approaching a casualty on the battlefield.

Remember to protect yourself.

a. Scan the area for potential danger.

(1) Survey the area for small arms fire.

(2) Survey the area for fire or explosive devices.

(3) Determine threat for chemical or biological agents.

(4) Survey buildings, if any, for structural stability.

b. Determine the best route of access to the casualty and the best route of egress. If you need to move the casualty to a safer area, be sure to select an area that provides optimum cover and concealment. Plan your evacuation route prior to exposing yourself to possible hostile fire.

c. Request covering fire during movement to and from the casualty's location to reduce the risk to yourself and the casualty.

d. Anticipate the type of injuries the casualty may have received and what care will probably be needed. Did the casualty fall from a wall? (If so, the casualty may have broken bones.) Was there an explosion? (If so, the casualty may have blast effects.)

Was there small arms fire? (If so, the casualty may have bleeding wounds.)

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e. Anticipate how your actions (movement, noise, light, and so forth) may affect the enemy's fire.

f. Decide what care you can administer when you reach the casualty and what care will have to wait until you have moved the casualty to a place of safety.

2-4. PROVIDING CARE UNDER FIRE

If the casualty cannot move himself to a place of safety and the combat situation allows you to safely assist the casualty, quickly evaluate the casualty, control any life-threatening bleeding from the extremities, and move the casualty and yourself to a safe location.

a. Approach the casualty by the safest route.

b. Form a general impression as you approach the casualty (extent of injuries, chance of survival, and so forth).

c. Upon reaching the casualty, determine his responsiveness (paragraph 2-5 below).

d. If the casualty has an amputation of a limb or live-threatening bleeding from a wound on a limb, quickly apply a tourniquet (paragraph 2-6 below and paragraph 4-10 of Lesson 4).

e. Move the casualty and yourself to a place of safety where you can perform tactical field care (paragraph 2-7). When moving the casualty, take the casualty's weapon and other mission-essential equipment with you if possible.

f. Listed below are some situations in which you should avoid treating the casualty while under fire.

(1) Your own life is in imminent danger.

(2) There are other soldiers in your area who require treatment more urgently.

(3) The casualty does not have vital (life) signs; that is, the casualty is not breathing, does not have a pulse, and is not moving.

2-5. CHECKING THE CASUALTY FOR RESPONSIVENESS

NOTE: You may need to wait until you can safely provide tactical field care to fully perform this procedure.

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a. Upon reaching the casualty, check the casualty for responsiveness.

(1) Ask in a loud, but calm, voice: “Are you okay?” Gently shake or tap the casualty on the shoulder.

(2) If the casualty is conscious, ask where it hurts or where his body feels different from usual. This helps to determine the level of consciousness and provides you with information that can be used when treating the casualty.

b. Ask the casualty questions to determine his level of consciousness. Ask the casualty questions that require more than a "yes" or "no" answer. Examples of such questions are: "What is your name?", "What is the date?", and "Where are we?"

(1) The AVPU scale is used in determining the casualty's level of consciousness. The four levels used in the AVPU scale are given below.

(a) A--The casualty is alert (knows who he is, the date, where he is, and such).

(b) V--The casualty is not alert, but does responds to verbal (oral) commands.

(c) P--The casualty responds to pain, but not to verbal commands.

(d) U--The casualty is unresponsive (unconscious).

(2) The following are some guidelines to use when assessing the casualty's level of consciousness.

(a) A casualty who is yelling at you, telling you where the enemy fire is coming from, or performing similar actions is alert.

(b) If the casualty is alert or responds to voice, do not check the casualty's response to pain.

(c) To check a casualty’s response to pain, rub his breastbone (sternum) briskly with your knuckle.

2-6. CONTROLLING HEMORRHAGING

Quickly check the casualty for potentially live-threatening hemorrhaging (severe arterial bleeding) from an extremity. For example, the shirt sleeve or pant leg may be red from bleeding. If severe bleeding is found, quickly apply a tourniquet high on the injured limb over the uniform and tighten it to stop arterial bleeding (see Section II of Lesson 4). Remember, bleeding from a wound on the extremity is the greatest cause of preventable death on the battlefield (paragraph 1-4).

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a. If the casualty has an amputation of the arm, forearm, thigh, or leg, apply a tourniquet even if the wound does not show serious hemorrhaging. The body's natural defenses may control the bleeding initially, but severe hemorrhaging will soon occur.

b. Do not waste time trying other techniques to control bleeding, such as a pressure dressing. Once you have reached a safe location, the tourniquet can be reevaluated and other techniques can be applied, if appropriate (see paragraph 2-8a), 2-7. MOVE THE CASUALTY TO SAFETY

After you have taken measures to control major hemorrhaging, you should seek safe cover for you and the casualty. If the casualty cannot move on his own or needs assistance, use a manual drag or carry. Some examples of manual drags and carries are given below. Once you and the casualty are in a safe location, you have moved from the care under fire phase to the tactical field care phase. See Lesson 9 for additional information on drags, manual carries, and drag equipment.

a. Drags. Drags are used to move a casualty quickly for a short distance.

Figures 2-1, 2-2, and 2-3 illustrate some of the drags used. A two-person drag (figure 2-2) can move a casualty easier and quicker, but exposes two soldiers to enemy fire.

Figure 2-1. One-person drag. Figure 2-2. Two-person drag.

Figure 2-3. Cradle drop drag.

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b. Carries. Carries involve lifting the soldier from the ground. The Hawes carry (figure 2-4) is the preferred one-person carry for moving a soldier. If the casualty is conscious and can assist, the one-person support carry (figure 2-5) may be used.

Remember, a casualty with all of his gear may weigh around 300 pounds. A two-person carry, such as the modified two-person fore-and-aft carry (figure 2-6) or the two-person support carry (figure 2-7), can sometimes be used, but they are difficult and will expose another soldier to enemy fire.

Figure 2-4. Hawes carry. Figure 2-5. One-person support carry.

Figure 2-6. Modified two-person Figure 2-7. Two-person support carry.

fore-and-aft carry.

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2-8. PERFORMING TACTICAL FIELD CARE FOLLOWING CARE UNDER FIRE

Initiate tactical field care when you and the casualty are no longer under direct enemy fire. In tactical field care, you have more time to provide care. However, the tactical situation can change and you could find yourself back in a care-under-fire situation. In tactical field care, available medical equipment and supplies are limited to that carried into the field by the combat lifesaver and individual soldiers. Tactical field care is discussed in greater detail in Lesson 3. However, the procedures for performing tactical field care following care under fire are briefly discussed below.

a. Reassess Tourniquet, if Appropriate. If you treated the casualty in a care-under-fire situation and applied a tourniquet to stop bleeding on an extremity, reassess the bleeding.

(1) Expose the wound and determine if a tourniquet is actually needed.

(2) If a tourniquet is necessary, apply a second tourniquet directly on the patient’s skin two to four inches above the wound and tighten it (see Section II of Lesson 4). After the second tourniquet is applied, remove the original tourniquet that you applied over the injured soldier’s uniform.

(3) If a tourniquet is not necessary, use a pressure dressing, direct pressure, elevation, and/or a hemostatic agent such as Combat Gauze™ to control the bleeding, then remove the tourniquet (see Section I of Lesson 4). By converting the tourniquet to a pressure dressing or controlling the bleeding by other methods, you may be able to save the casualty's limb.

WARNING

If tourniquet has been in place for more than six hours, do not attempt to remove the tourniquet. Removing a tourniquet after six hours should only be performed by medical personnel.

b. Check for Life-Threatening Hemorrhage. Check the casualty for any untreated wounds on the extremities that are life-threatening and treat them. See Lesson 4.

c. Continue to Evaluate and Treat. Continue to evaluate and treat the casualty,

(1) Take measures to maintain the casualty's airway, including inserting a nasopharyngeal airway if needed. See Lesson 5.

(2) Treat any open chest wounds. See Section I of Lesson 6.

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(3) Continue to treat other injuries (splint fractures, bandage other wounds, and so forth).

(4) Administer pain medications and antibiotics (combat pill pack). Use the casualty's combat pill pack. Do not use your own pack since you may need them yourself and you have no extra combat pill packs in your aid bag.

(5) Take measures to prevent and treat shock (paragraph 3-12 of Lesson 3).

d. Communicate the Situation. Communicate the medical situation to the unit leader.

(1) Send a soldier for medical help (combat medic), if appropriate.

(2) Let the unit leader know if the casualty will not be able to continue his mission.

e. Monitor the Casualty. Monitor the casualty's level of consciousness and breathing.

(1) Recheck the casualty's level of consciousness (AVPU scale) about every 15 minutes to determine if the casualty's condition has changed. Maintaining a check on the casualty's level of consciousness is especially important if the casualty has suffered a head injury.

(2) If the casualty has an open chest wound, is having trouble breathing, and the difficulty in breathing is increasing, perform needle chest decompression (see Section II of Lesson 6).

(3) Let the unit leader know if there is any significant change in the casualty's status.

f. Prepare Casualty for Evacuation, if Needed.

(1) Record your evaluation and treatment on a Field Medical Card, Tactical Combat Casualty Care Card, or similar document. Attach the document to the casualty's clothing or place it in an appropriate pocket on the casualty (Lesson 7).

(2) Request a medical evacuation (MEDEVAC), if appropriate (Lesson 8).

(3) Evacuate a casualty using nonmedical means (CASEVAC), if needed (Lesson 9 and Lesson 10).

(4) Continue to monitor the casualty and keep the unit leader informed of any major change in the casualty's condition.

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EXERCISES: LESSON 2

INSTRUCTIONS: Answer the following exercises by marking the letter of the response that best answers the question or best completes the sentence or by writing the answer in the space provided.

After you have answered all of the exercises, check your answers against the

1. How does evaluation and treatment of a casualty in a care under fire situation differ from secure (tactical field care) situation?

2. Your unit is in ground combat. You see a soldier fall as though he has been shot.

Your primary duty is to:

a. Continue firing at the enemy.

b. Stop firing and go to the fallen soldier.

3. What type of preventable condition do more soldiers die from during ground combat before reaching a medical treatment facility?

a. Tension pneumothorax.

b. Blocked airway.

c. Bleeding from wounds to the extremities.

d. Wound infection.

4. When performing care under fire, which of the following actions can be performed before moving the casualty to a safe location?

a. Perform cardiopulmonary resuscitation (CPR).

b. Applying a tourniquet to control bleeding.

c. Perform needle chest decompression to relieve tension pneumothorax.

d. Administer the combat pill pack to control pain and infection.

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5. You and another soldier are in the open and separated when you both come under enemy fire. The other soldier is wounded, but is conscious and able to fire his weapon. What should you tell him to do?

6. You have come under enemy fire. You and another soldier have taken cover together. The other soldier has a severe bleeding wound to his arm. You can administer treatment without endangering the mission or yourself. What treatment should you administer?

7. You are going to the aid of an injured soldier while under fire. What should be your first action upon reaching the soldier?

a. Check the soldier for responsiveness.

b. Check the soldier's pulse.

c. Check the soldier for breathing.

d. Check the soldier for shock.

8. A casualty is lying very still. He does not respond to any of your questions or commands. He does show a reaction when you rub his breastbone briskly with your knuckle. How would you classify the casualty on the AVPU scale?

a. A.

b. V.

c. P.

d. U.

9. You are determining the casualty's level of responsiveness. The casualty tells you that he has been shot in his leg and that he is in pain. How would you classify the casualty on the AVPU scale?

a. A.

b. V.

c. P.

e. You cannot classify the casualty until you complete your testing.

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10. When should you plan how to move a wounded soldier out of enemy fire?

a. Before you leave your place of safety to go to the wounded soldier.

b. As soon as you reach the wounded soldier.

c. As soon as you have treated the life-threatening conditions.

d. As soon as you have treated all of the casualty's injuries.

11 You have been wounded and are still under enemy fire. You are unable to return fire and there is no safe cover nearby. What should you do?

12. You can move a casualty out of enemy fire and to a safe location. Should you also try to move the casualty's weapon to the safe location?

13. A casualty has been shot in his left foot, but can still hop on his right leg. Which of the following should you use to move the casualty to safety?

a. Cradle drop drag.

b. Neck drag.

c. Support carry.

d. Whichever is the safest for you and the casualty.

14. You applied a tourniquet to a soldier's wounded leg before dragging him to a safe location. What should do about the tourniquet once you and the casualty are safe?

a. Nothing. Leave the tourniquet in place.

b. Examine the wound to see if it the bleeding can be controlled using other means.

c. Place another tourniquet above the first tourniquet and leave both tourniquets in place.

d. Place another tourniquet above the first tourniquet and remove the first tourniquet.

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15. You applied a tourniquet to a soldier about eight hours ago. The tactical situation now allows the casualty to be evacuated. Should you loosen the tourniquet and try to control the bleeding with a pressure dressing before evacuating the casualty?

16. Inserting a nasopharyngeal air to maintain the casualty's airway as part of:

a. Care under fire.

b. Tactical field care.

c. Both care under fire and tactical field care.

17. Which of the following is NOT part of care under fire?

a. Moving the casualty to safety.

b. Checking the casualty's level of consciousness.

c. Treating an open chest wound.

d. Applying a tourniquet.

18. What is the advantage in using a two-person drag or carry to move a casualty to a safe location while in a care under fire situation?

19. What is the disadvantage in using a two-person drag or carry to move a casualty to a safe location while in a care under fire situation?

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20. The Hawes carry is commonly used carry. Which of the following illustrates the Hawes carry?

a. b.

c. d.

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SOLUTIONS TO EXERCISES: LESSON 2

1. While under fire, you only treat life-threatening bleeding from a limb. In a secure environment, you can focus more on the evaluation and treatment of the casualty, including the airway, open chest wounds, fractures, and nonlife-threatening injuries. (paras 2-4, 2-6, 2-8)

2. b (para 2-2)

3. c (paras 2-6, 1-4)

4. b (paras 2-4d, 2-6)

5. Seek cover; return fire; administer self-aid. (para 2-2f)

6. Apply a tourniquet to control bleeding (para 2-4d)

7. a (paras 2-4c, 2-5a)

8. c (paras 2-5b(1)(c), b(2)(c)

9. a (paragraphs 2-5b(2)(a)

10. a (para 2-3b)

11. Play dead. (para 2-2h)

12. a (para 2-4e)

13. d (para 2-7)

14. b (para 2-8a) Note: If a second tourniquet is applied, it will probably be applied below the first tourniquet.

15. b (para 2-8a Warning)

16. b (paras 2-4, 2-8c(1))

17. c (paras 2-4, 2-8c(2))

18. A two-person drag or carry is easier and quicker. (paras 2-7a,b)

19. Two rescuers are exposed to enemy fire rather than one. (paras 2-7a, b)

20. c (fig 2-4)

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LESSON 3

TACTICAL FIELD CARE

Tactically manage a simulated casualty.

CONDITIONS

Given a written situation concerning a casualty in a tactical field care situation and possible responses.

STANDARDS

Select the correct response based upon instruction given in Subcourse IS0871.

REFERENCES

STP 21-1-SMCT, Soldier's Manual of Common Tasks: Skill Level 1.

3-1. INTRODUCTION

In tactical field care, you and the casualty are not under effective enemy fire and you are free to provide care to the best of your ability. However, medical equipment and supplies are limited to that carried into the field by the combat lifesaver and by individual soldiers.

a. Tactical field care covers two situations.

(1) In combat, tactical field care may be given by the combat lifesaver after the casualty has been moved to a safe location. However, the tactical situation can change and you could find yourself back in a care-under-fire situation or even told to stop rendering aid and resume your primary combat functions.

(2) Tactical field care also refers to care rendered by the combat lifesaver when the casualty is not in a care-under-fire situation to begin with, such as a soldier who falls while trying to climb a wall or cliff or a soldier who is injured by an explosion when no enemy troops are in the area.

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b. The first situation was covered in Lesson 2. The second will be covered in this lesson. It is assumed that you locate a casualty while you are not in danger from enemy fire and you can render care to the casualty without endangering your mission.

3-2. INFORM YOUR LEADER

When you discover a casualty, communicate the situation to the unit leader as soon as you can. This is done to ensure that the tactical situation allows time to treat the casualty before initiating medical procedures.

a. Send a soldier for medical help (combat medic), if appropriate.

b. Once you have examined the casualty, let the leader know if the casualty will not be able to continue his mission.

c. Once you have treated the casualty, let the unit leader know of any significant change in the casualty's status.

3-3. APPROACH THE CASUALTY

a. When approaching the casualty, scan the area for potential hazards.

Approach the casualty using a safe route. Keep from becoming a casualty yourself.

(1) Survey the area for possible enemy actions, such as small arms fire.

(2) Survey the area for fire or explosive devices and for possible chemical or biological agents.

(3) Survey any nearby buildings for structural stability.

b. As you approach the casualty, form a general impression of the casualty.

See if you can anticipate the type of injuries the casualty may have suffered and the type of care you will need to administer.

3-4. CHECK THE CASUALTY FOR RESPONSIVENESS AND LEVEL OF

CONSCIOUSNESS

When you reach the casualty, check the casualty for responsiveness and determine the casualty's level of consciousness.

a. Responsiveness.

(1) Upon reaching the casualty, ask in a loud, but calm, voice: “Are you okay?” Gently shake or tap the casualty on the shoulder.

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(2) If the casualty is conscious, ask him where it hurts or where his body feels different from usual. This helps to determine the casualty's level of consciousness and provides you with information that can be used when treating the casualty.

b. Checking Level of Consciousness.

(1) Ask the casualty questions to help determine his level of consciousness.

Ask the casualty questions that require more than a "yes" or "no" answer. Examples of such questions are: "What is your name?", "What is the date?" and "Where are we?"

(2) If the casualty does not respond, check him for response to pain by rubbing his breastbone (sternum) briskly with your knuckle.

c. Determine Level of Consciousness. Determine the casualty's level of consciousness using the AVPU scale discussed below. Changes in the casualty's AVPU rating may indicate changes in his medical condition, especially if the casualty has suffered a head injury. Check the casualty's level of consciousness about every 15 minutes.

(1) A--The casualty is alert (knows who he is, the date, where he is, and so forth).

(2) V--The casualty is not alert, but does responds to verbal (voice) commands.

(3) P--The casualty responds to pain, but not to verbal commands.

(4) U--The casualty is unresponsive (unconscious).

NOTE: A casualty who is yelling at you, telling you what happened, or performing similar actions is alert.

NOTE: If the casualty is alert or responds to voice commands, do not check the casualty's response to pain.

3-5. POSITION THE CASUALTY ON HIS BACK

Position the casualty on his back if he is in a prone…