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Tactical Combat Casualty Care

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Source material document here provided by UOTC.

TCCC and its MilSim impact

TCCC stands for Tactical Combat Casualty Care;
a standardized NATO procedure guideline with aim to provide help for the correct analyzation of tactical situations when medical emergencies occur and for suggested methods of treatment phases and treatment priorities. Everything included in this guideline describes the stage of a player becoming a casualty to the point where he arrives at a medical facility for advanced and / or final treatment, if available.

As most milsim players have no military background the task of determining the correct intervention, while keeping the aspects of tactical conditions in mind, is most likely not intuitive, much less in a virtual simulated environment.

This guide aims for navigating the issue with the player assuming that immediate care of himself or friendly wounded players is his first priority. While honorable and surely only executed with the best intents, on the simulated battlefield this behaviour is dangerous and can actually lead to more casualties and therefore reduced combat effectivity of the fighting elements and ultimately mission failure. (Good medicine might be bad tactics).

Casualties

When looking at the medical circumstances in missions on our UO server there are some very recognizable reasons for reduced effectivity of elements once casualties occur:

  • Individual players being unfamiliar with the medical system in use
  • Individual players being unfamiliar with basic casualty care procedures
  • Individual players being unfamiliar with basic first aid procedures
  • Leadership incapable of integrating medical assets / procedures in their intended use
  • Leadership unwilling to integrate medical assets / procedures in their intended use (something we can not fix with knowledge or courses, only with persistence)
  • Mission providing insufficient equipment to medical personnel
  • Inexperienced players slotting in medical roles, failing to provide needed input & care

Make good use of the procedures provided, while adapting (in reasonable scale) to your current tactical situation.

Question:

What are important causes for casualties that can be easily fixed on individual level?
(try to answer this question by yourself first, before reading the list below)

The ‘Cluster Fuck’ or ‘Charlie Foxtrot’ Incorrect use of cover and character stances Incorrect ‘reaction to casualties’
Describes a situation in which a group of players give up their individual spacing and bunch up in close proximity due to the effectivity of enemy fires, carelessness or lag of experience. These are usually primary targets for any enemy indirect or suppressive fire elements. Usually occurring on individual level by being unable to predict how the player model behaves in cooperation with the virtual environment and how it is exposed to the opposing team or AI. Individuals or entire teams might react incorrect to a player turning into a casualty, ending up risking their entire team or leaving the casualty behind because no one recognized the players condition.

So far the primary reasons observed for casualties actually dying after being wounded are:

  • Timeframe until being recognized as a casualty.
  • Quality of treatment on the casualty.
  • Insufficient individual first aid.
  • Hypovolemia caused by excessive blood loss.

In combat circumstances or even mass casualty events, the wounded are categorized into three groups.
If no medical staff is present at time, this categorisation needs to be controlled by the player in the highest rank not belonging to any of the three categories (therefore not being wounded) to the best of knowledge:

  1. Casualties who will die, regardless of any medical aid
  2. Casualties who will live, regardless of any medical aid
  3. Casualties who will die, when not receiving timely and appropriate aid

The TCCC procedures explained below address the third category of casualties, which is the category that requires direct medical attention.

Medical attention and the influence of combat

In combat the treatment of casualties is a complicated procedure.
In addition some of the following circumstances might add difficulties to the process:

  • The treatment might be impossible due to the presence of effective enemy fire.
  • There is only so much medical equipment available as carried by the rescuer and casualty.
  • The current combat situation might require to prioritize mission completion over casualty care.
  • Rapid casualty evacuation might not be available due to mission design.

The goals of TCCC and the three treatment stages

Aim of TCCC is to provide the correct medical and tactical intervention at the correct time with the following goals:

  1. Treat the casualty
  2. Prevent additional casualties
  3. Complete the mission

Achieving these goals TCCC uses three stages/phases of treatment/care:

  1. Care under fire
  2. Tactical field care
  3. Tactical evacuation care

TCCC - Care Under Fire

Care und Fire Is the care provided at the location where a player turned into a casualty, while both, rescuer and casualty, are under sporadic or constant effective enemy fire. The risk of additional injuries for the casualty and the rescuer are extremely high!
Before a rescue attempt is started the following aspects should be revisited:

  1. Suppression of hostile fire or gaining fire superiority to a degree that allows successful movement of the casualty.
  2. Assessment of the availability of near terrain or hardcover from known hostile positions that the rescuer can move the casualty to.
  3. Covered movement to the casualty and immediate application of tourniquets on any bleeding limb.
  4. Moving the casualty to previously determined cover.

Possible Complications

This stage can additionally be made more complicated and dangerous by the following circumstances:

  • The available medical equipment is limited to what is carried by the casualty and the rescuer.
  • The players on location will be occupied with engaging hostiles and therefore likely be unavailable to assist in treatment or evacuation of casualties.
  • A specific tactical situation might prevent the rescuer from appropriately examining or treating the casualty.
  • Incidents during night operations usually result in severe visual limitations when trying to move, examine, treat or evacuate a casualty.

Available Defensive Actions

While the stage of ‘care under fire’ the following defensive actions might be required to be performed prior to the actual first steps:

  • To gain sufficient suppression or fire superiority over the hostiles, the rescuer might be in need to help return the fire prior to initiating casualty care.
  • Casualties whom have not sustained any lethal injuries are also required to continue to fight and return fire to the best of their ability.
  • Gaining fire superiority is essential to the success of any rescue operation!
  • Additionally medically trained personnel like combat lifesavers, combat first responders and medics should be equipped with personal defense weapons used to defend themselves and the casualty in this stage.

Death by Blood Loss

In ArmA3 using the ACE3 medical_system the most essential threat to casualty survival is blood loss. Therefore the immediate control of said is a primary task for the rescuer. Remember that in this stage rescuer and casualty remain in high danger of sustaining additional injuries. If conscious the casualty should apply a tourniquet to any bleeding limbs (arms and legs) immediately. If the casualty is waking up from the unconscious state his first task should as well be to apply a tourniquets to any bleeding limbs and starting to bandage himself without direct exposture to enemy fires. It decreases the time and therefore the threat the rescuer needs to expose himself to, while performing care und fire on the casualty on arrival.

Upon arrival at the point of injury the rescuer is to quickly assess the casualty and to apply tourniquets to all bleeding limbs, before moving the casualty and himself to the closest available terrain or hard cover that he perviously decided on.

Methods of Casualty Transportation

While providing casualty care under fire, the situation usually permits advanced methods of casualty transportation.

The recommended method of moving a casualty in this stage is to use the ace drag option as the carry option would expose you and the casualty in upright stature to enemy fires. When using the ace drag option your character will grab the casualty on his carry plate neck hose and give you the ability to drag in prone or crouched stance with reduced speed.

Approved Support

The following possibilities can increase the success of this stage:

  • The use of smoke or CS gas onto known or suspected enemy positions can increase the chance of a successful retrieval. Under NO circumstance should the own position be smoked! This would provide an obvious reference to the enemy which will most likely result in immediate engagement by enemy fire support and or indirect fires destroying any forces at the marked location.
  • If the enemy smokes your position, it is highly advised to break of any rescue attempts and relocate instantly. A ‘grab and run’ could be considered to save the casualty when no fire is incoming through the smoke and the casualty is a.) visible and b.) covered from enemy eyes by the smoke.
  • Medium or heavy armored vehicles can be used to shield retrieval attempts, but require assessment of enemy AT capabilities. If the threat is too high, such attempt could lead to disaster.

When arriving at the secure location the ‘care under fire’ stage of TCCC ends.

TCCC - Tactical Field Care

Is the care that is provided to the casualty by the rescuer when both are in secure location and no longer under effective enemy fire. Under ideal condition this location is covered by friendly players.
Hint: Remember that this stage also applies when there has been a casualty in field and no enemy fire has been received (IEDs, mines, falling of a roof on Zargabad,...).
The second phase of care identifies by the following points:

  • Risk from hostile fires has been reduced. Re-engagement is possible.
  • Any available equipment is still limited to what is carried by mission personnel.

During this phase treatment should be more in-depth and covers additional topics that could not be addressed while under fire. Even if the risk in this stage is reduced the treatment process is still dictated by the current tactical situation.

Core assumption for tactical field care is a re-engagement with enemy forces at any moment. Therefore rapid treatment of wounds is applied by using standardized methods.

Basic First Aid Procedures

In the second stage first aid procedures are initiated. These procedures are simple and easy to remember. You should definitely be able to recall these under all circumstances.

Bleeding Control

Entry condition:

  • Tourniquets are applied to ALL bleeding limbs
  • There are additonal bleeding limbs on the casualty
  1. Asses wounds on torso & head
  2. Bandage torso then head wounds from large, over medium to small
  3. Bandage wounds on tourniqueted limbs, again from large, over medium to small
  4. When all wounds are bandaged, remove the tourniquets
  5. Reasses your wounds frequently until stitched

Acquire Casualty Status

In ArmA3 with ACE we want to insert a step that is not included in the official TCCC guideline: We need to acquire the status of the casualty, assuming that ACE3 hopefully somewhen will integrate the feature that all unconscious players automatically ragdoll. Currently in ACE 3.9.0 a ragdolled player is positively, absolutely stone dead. This can be acquired even before starting a casualty retrieval.

To determine a casualty’s status in a non-medical role we execute a blood pressure and heart rate check. The following simplified(!) combinations can help:

BP (120/80) HR (~80 bpm) Wounds? Lost a lot of blood? Possible Condition
Low High All Over Yes Expect cardiac arrest!
Low None 1 Large
1 Medium
1 Small
No Possible use of wrong medication,
revisit the medical log.
Request CLS, bandage wounds and provide CPR until superseded.
High High Some No Possible use of wrong medication.
Expect cardiac arrest!
Request CLS for further treatment.
Low None Many Yes Cardiac arrest due to hypovolemia.
Bandage all wounds.
Request CLS and provide CPR until superseded.

First Aid no-gos. Read this! YES, YOU!

Do not do anything of the below:

  • Administer Drugs by your own judgement. (This has no place in first aid. Pain can not kill a player. Wrong medication combined with unlucky circulatory system conditions can VERY EASILY!)
  • Apply cardiopulmonary resuscitation (CPR) while the patient has bleeding wounds.
  • Carry the casualty while he is bleeding excessively.
  • Leave the casualty before being superseded. If the tactical situation forces your team to advance, make sure a rear element member takes over your duties. Communicate any important information that you gathered while examining the casualty.

END OF FIRST AID CHAIN

If you are non-medical personnel the first aid chain ends here!

Make sure to, from time to time, check if any wounds did open up and close them immediately.

Wait until superseded by medical personnel.

Advanced Treatment And Evaluation

[Hello. If you continued to here you might be a player with advanced medical knowledge or one that wants to expand on his basics. I want to encourage you to partake in the UOTC Combat Lifesaver Course (once available) after reading this material.]

While the phase of tactical field care monitor the casualty constantly and reassess its condition on a frequent basis. Assuming you are a CLS you should make your superior aware that he should call in a medic (if not already at work) ASAP, to supersede you so you can go back to your infantry duties.

Based on the mission design you might be able to administer basic drugs. Make sure that you know the effect these have onto the casualties medical status before using them.

Pain Control

With ACE3’s medical_system pain can be a cause for unconsciousness of a casualty. Be aware of the fact though, that the casualty, when unconscious from pain, will wake up frequently. The frequency is connected to the level of pain.
Pain is an element that can only be suppressed by drugs, but not be removed by them. Depending on the remaining conditions of the casualty, being unconscious might not be caused by the amount of blood loss. Observe carefully.
Administer pain relieving drugs as required after being sure it won’t worsen the casualties condition. Pain level will lower itself over time, depending on the casualties status. Open wounds cause the pain level to rise. Each wound seems to currently add to the overall pain level of the casualty. This is visualized by a white flash starting on the outer parts of the screen. The higher the pain level the closer the white flashing area will cover to the center of the screen. You can quickly evaluate how high the possibility of frequent unconsciousness on a casualty might be, by asking him for how much of his screen is covered by the flashes.

Documentation

In terms of documentation I recommend to at least note any special findings about the casualties under your care as well as to look at their condition and set their medical triage status to whatever you deem appropriate. Triage will be explained later in this document, to estimate a casualties triage status, make sure to apply the mentioned methods of identification.
All documented findings should be quickly explained to the medic upon arrival.

TCCC - Tactical Evacuation Care

Once the casualty has been picked up by an rotary wing aircraft, vehicle or boat with the intend to be transported to a medical facility for advanced/final treatment the third stage of care is entered.

Upon arrival of the medical evacuation team the local medical care provider (Medic or CLS/CFR) quickly explains any special documented informations about the casualties.

This stage is basically a continued status of the care in the second stage with additions such as:

  • Additional medical personnel might accompany the evacuation team.
  • Additional medical supply might be delivered with the CASEVAC asset.

Having additional medical personnel with the CASEVAC element might be important out of the following reasons:

  • Local medical staff might be part of the casualty group.
  • The amount of casualties exceeds the medic's capability of simultaneous care.
  • Medical personnel in the CASEVAC element is of higher experience and input is required.

TCCC - Triage Categories

In battle the medical staff has to be able to quickly determine a casualty's condition, it’s needs and if they can provide these or not.
Following points can initiate the need to establish medical triage:

  • The platoon medic or highest ranking medical personnel determines that available supplies will not be sufficient to treat all casualties.
  • The amount of available personnel for medical help to casualties might not be sufficient to treat all patients simultaneously.
  • Tactical situation might dictate that specific casualty groups need to be extracted before others based on location.

! ATTENTION !

At this point it should be mentioned that the triage system effectively negates the chain of command in terms of medical attention.

The triage system evaluates based on chances of survival and available supply, not rank, usefulness or popularity.


The following categories are defined: