Care under Fire Reloaded

US Pararescue Jumpers in Care under Fire exercise
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Care under Fire Reloaded is the first of a series of articles regarding the fundamentals of Tactical Combat Casualty Care. It is an attempt to create some clarity, point out solutions, and generate some discussion. "What worked yesterday would be fine, if it was yesterday”. We are obliged to those we serve to constantly strive for excellence.

Whiskey Delta Gulf CuF Definition

The USA CoTCCC defines Care under Fire (CuF) as “the care rendered by the first responder or combatant at the scene of the injury while he and the casualty are still under effective hostile fire. Available medical equipment is limited to that carried by the individual or by the medical provider in his or her aid bag.” The Canadian CCCWG defines Care under Fire (CuF) as “a situation during active combat where both the casualty and the care giver may or may not be behind adequate cover, and both or at least the care provider, are required to contribute to the engagement”.  I do not believe either definition is complete. Therefore, does not provide the required guidance to the tactical medic or operator providing care. Both, definitions reference active combat as the definitive factor in deeming the level of care provided.  I warrant that the tactical situation, not rounds in the air, define the moment more correctly. After a casualty inflicting IED strike there are many threats that will limit the level of care provided. The threat of a subsequent small arms ambush, the danger of secondary and tertiary IEDs, the removal of casualties from burning vehicles are all elements of the tactical situation that would influence care. Yet, there is no active combat. In a HAZMAT or CBRN operation, the environment itself is the greatest threat. Even after any gunfight, that area would be extremely dangerous. Care under Fire (CuF) is care rendered when the care provider is engaged in active combat or situations when there are active or subsequent threat(s) that endanger casualty or casualties and care provider and/or limits time and opportunity to provide care. 

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The CoTCCC guidelines for the Basic Management Plan for Care under Fire phase are rather rudimentary. I understand that they are guidelines. They were written in this manner to allow the care provider freedom of maneuver and to avoid a dogmatic approach to casualty care such as exist in civilian EMS. However, there are important aspects to this dynamic phase of care that are not touched upon by these guidelines.  There is not a situational awareness (SA) step. Taking the seconds to update your SA is a necessary part of your risk versus benefit assessment. Removing casualties from a burning vehicle is mentioned specifically. Extrication of casualties from a dangerous area would fall under the area of Tactical Rescue. Why write guidelines that limit it to only one situation? Tactical Rescue is a possibility in any tactical scenario or dangerous environment. It is a very important aspect of CuF that gets little to no attention or training. There is little mention of communication; a fundamental of teamwork. Furthermore, it is a linear model. Combat is not linear, it flows. The guidance must reflected that. Below is a set of guidelines that address these issues.

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Practically, there has been little change to the Basic Management Plan for Care under Fire for many years. Most of the changes to TCCC guidelines have mission and threat dependent  This, I believe, is a mistake. While specific mission threats and treatments must be addressed through medical protocols, the guidance must remain pertinent to any deployment anywhere anytime. Who knows where we will go next? We cannot be slaves to our most recent experiences in Afghanistan or Iraq.  Tactical Combat Casualty Care is here to stay.  Like all tactical skill sets, it must be improved, innovated and revolutionized. 

Take care out there.