Wednesday, May 9, 2018

First Aid: TCCC III - Tactical Casualty Evacuation

Hour 6

TCCC Quick Reference Guide 2017 pp. 8, 21-32
Warrior Skills Level 1, pp. 3-89 through 3-92
First Aid, Appendix B, pp. B-1 through B-28

[Important Note: This is information is given, knowing that it relies on a level of support and a standard of care that you may or may not have complete access to in whatever tough times you and your group size may face. You still ought to know the principles, because you may still have it to some degree (e.g. even in Venezuela, today, there are still hospitals, humble and limited though their interventions may be amidst a societal meltdown). One clear takeaway, via common sense, should be to imagine the incapacitation of a member of your group in a patrol-like situation. If you don't have enough people to send to be able to self-evacuate a wounded, injured, or otherwise incapacitated member, on foot (like say 2-4 healthy individuals to carry a litter case for a prolonged period and for some number of miles in urban or rural terrain) then any "patrol" is essentially a suicide mission for them, and you don't have the people available to be doing such patrols in the first place. If your casualty contingency plan on any walkabout is limited to minor injury care for "walking wounded", or else "Perform Last Rites", the only people participating on such endeavors with you are either suicidal, or too stupid to seriously depend upon, and the healthy response of your colleagues to your intentions will be a heartfealt and sincere "Get f**ked, mate" from one and all, as it should be.

 If you're assuming medical contingency support that doesn't exist, and that you haven't expressly planned for, Reality is going to take a great big bite out of your ass (or that of someone else near or dear to you), and even TCCC won't be able to help you. In laymen's terms, without that handy doctor aboard, the entire cast of Firefly is dead before they even get as far as the episode when they were cancelled, a few episodes into their only season. That's how real life works. Think about that reality long and hard as you consider your own state of preparations for future contingencies. This what grown-up planning looks like.]

Tactical Casualty Evacuation continues the care of your patient/casualty, while getting them ready for removal to higher care. It's applicable whether that evacuation is by you carrying them out on a patient litter on foot, putting them in a dedicated or ad hoc vehicular ambulance, or a first-world air medical evac actually swoops in and gets them to definitive care.

Once again, if you're not planning for casualties, YOU'RE NOT PLANNING, YOU'RE FANTASIZING. If that's the case, stop right here, get a crowbar, and endeavor to remove your head from what black-hatted airborne instructors lovingly refer to as your Fourth Point Of Contact.

The phase is best studied in the original materials.
It breaks down into three subsections.

1) Communicating the casualty's information and status to higher direction and to casualty evacuation personnel, and preparing for that transition. For the military, that's a 9-Line Medevac Request.
2) Continued monitoring and interventions as necessary for your patient's ongoing Airway, Breathing, Circulation, and other injuries, needs, and ongoing or new conditions, for as long as it takes between stabilization for transport, and their actual removal to higher levels of care, whether for minutes, hour, or even days.
3) Communicating and re-assurance to any patients what their status is, what's being done for them, and what to expect after they get handed up and off.

Casualties with altered mental status should have any and all weapons and radios removed from their person. Panicky and injured people with weapons is never a good idea.

If handoff will be via transportation from medical or QRF transport, establish the site, and secure it.

Airway/Breathing/Circulation/Shock/Mentation should be re-assessed over and over again with each and all patients, their status ascertained, and any further interventions accomplished. If patients' status changes, this information should be relayed as appropriate to both team leader, and for any arriving medical evacuation.

If the patient is otherwise stable, this phase is also the appropriate time to maintain appropriate body warmth measures for patients, both to prevent shock and for comfort, and to address additional conditions less than life-threatening, and treat any less serious problems, including eye injuries, fractures and extremity injuries, and all lesser problems.
It's also the point where Pain Management comes in, and any and all pharmacological interventions (medication) should be considered/accomplished, to the limits of your abilities and authorization, and within your actual capabilities. Wounds hurt, pain increases stress, which increases the cardiac effort and respiration necessary, and thus worsens the likelihood of shock, so anything and everything you can do at this point should be considered, in light of medical protocols and available supplies.

The references TCC Guide includes notes in the back concerning all medications on the best-case list for administration. Even if all you have and can give is Tylenol, it's better than nothing at all.

You should also note that all steps in Tactical Evacuation Care are performable by medics and below, and the only interventions categorized as paramedic/18D (red) are endotracheal intubation, placement of a chest tube, and administration of blood transfusions. Everything else in the algorithm is categorized as appropriate as green (anyone) or yellow (basic EMT/trained-Medic-level).

There is also information on when and under what conditions CPR ought to be attempted (and note that there are some). Study them and know when to do it, and when it's probably a futile intervention. (You'll be there on the day, and no one else will be there to tell you. Learn it now.)

Other than learning the TCCC algorithms for this phase, and continually assessing and re-assessing your patient(s) until they are successfully transported/handed off, the best investment of your time is to learn how to package and move injured patients in a field setting, and practice doing it properly and safely.

The basics of it hasn't changed much since the 1970s:

You should also know how not to do it.

Funny to watch, but not nearly so funny for real, with people you know, who bleed, scream, and die when you f**k it up.

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