Updated August 20, 2015
During the mid-1990s, U.S. Navy Captain Frank Butler and others working with the Naval Special Warfare Command and U.S. Special Operations Command developed and published a framework for delivering medical care in the tactical setting.1 That framework is called Tactical Combat Casualty Care (TCCC), and it has become the standard for providing immediate medical care in a hostile environment.
The Committee on Tactical Combat Casualty Care created a three-phase framework based upon the environment and current threat levels. The Committee’s stated goals are to 1) treat the casualty, 2) prevent additional casualties, and 3) to complete the mission. This template is designed for anyone providing medical care, whether he or she is a professional medical practitioner or a teammate providing basic first aid.
Care Under Fire
The first phase is called Care Under Fire (CUF), and it defines the care to be provided while there is a direct and ongoing threat to the patient and medic.
It has been oft-stated in the military and tactical venue that the best medicine is fire superiority, and that is a key feature of the CUF phase. Despite the romantic Hollywood image of a medic spiking an IV bag with one hand while laying down suppressive fire with the other, it is almost never the case in the real world.
CUF is that aid which can be rendered very quickly to address an immediate life threat. This is commonly viewed as the placement of a tourniquet on a bleeding extremity, moving the wounded out of the line of fire if able, and little more. For the medic to lay his weapon down and focus his attention away from the threat only increases the risk to all involved.
Tactical Field Care
The Tactical Field Care (TFC) phase is that point in time when the threat is reduced or resolved but the patient is still in a tactically unstable environment. Perhaps the direct fire has temporarily stopped, or you and your patient have found some cover where you can focus safely on him rather than achieving fire superiority.
During this phase you can perform an initial patient evaluation assessing for H-A-B-C (life-threatening Hemorrhage, Airway, Breathing, and Circulation). You can re-check that tourniquet you may have applied earlier, dress wounds, perform a needle thoracotomy or start IVs as needed, and employ other emergency measures. It is important to remember that the TFC phase can be dynamic and the threat may quickly return, so dedicated efforts such as CPR are not initiated.
Tactical Evacuation Care
The Tactical Evacuation Care phase (TACEVAC), formerly called the Casualty Evacuation (CASEVAC) stage, will consist of medical treatment rendered during movement to the appropriate medical treatment facility. This care may range from continued treatment provided by the first responder during a hasty evacuation to a safe zone, to advanced medicine performed by dedicated medical crews en route to a trauma center. Movement of the patient away from the threat zone and toward definitive medical care is the defining feature of this phase.
The principles of Tactical Combat Casualty Care have been constantly refined and are in widespread use among military and civilian tactical teams for over a decade, with a track record of saving lives.2 Further incorporation of these guidelines and practices into teams not yet using them will help ensure the safety, health, and survivability of its members.
Endnotes
(1) Tactical Combat Casualty Care in Special Operations, CPT Frank Butler, Jr., MC, USN; LTC John Hagmann, MC, USA; ENS George Butler, MC, USN, Military Medicine, Vol. 161, Supp 1, 1996.
(2) An evaluation of tactical combat casualty care interventions in a combat environment, Tien HC, Jung V, Rizoli SB, Acharya SV, MacDonald JC, J Am Coll Surg. 2008 Aug;207(2):174-8. Epub 2008 May 12.
