- LEARNING OBJECTIVES
- Three PHASES of TCCC
- IMPORTANCE OF COMMUNICATION
- REQUESTING EVACUATION OF CASUALTIES
- REQUESTING EVACUATION - KEY POINTS
- NATO CASUALTY EVACUATION CATEGORIES
- CASUALTY EVACUATION CATEGORIES
- MIST REPORT
- TACEVAC PEARLS OF WISDOM
- CHECK ON LEARNING
Module 21: Communication Procedures
This module discusses the importance of and techniques for communicating effectively with casualties, unit leadership, and evacuation assets in the Tactical Field Care (TFC) phase of Tactical Combat Casualty Care (TCCC).
In Module 21 we will discuss the importance of and techniques for communicating effectively with casualties, unit leadership, and evacuation assets in the Tactical Field Care (TFC) phase of Tactical Combat Casualty Care (TCCC).
Tactical Combat Casualty Care is broken up into 4 roles of care. As a combat medic/corpsman, the first medical provider to care for the casualty and initiate more advanced treatments in the continuum of prehospital care, it is important that you understand the roles and responsibilities of the nonmedical personnel (All Service Members and Combat Lifesaver) who may be assessing and providing care/assisting in the treatment of casualties in the prehospital environment.
There are 3 cognitive and 1 performance learning objectives for the Communications module.
The cognitive learning objectives are: identify the importance of and techniques for communicating casualty information with evacuation assets and/or receiving facilities, identify the information requirements and format of an evacuation request, and identify the recommended evacuation prioritization for combat casualties.
The performance learning objective is to demonstrate the communication of evacuation request information and modified medical information report requirements.
Although immediate life-threatening hemorrhage control and the prevention and treatment of other immediately life-threatening injuries and complications are the focus, communication and documentation should be ongoing throughout the Tactical Field Care phase and continue as pre-evacuation procedures are initiated in the transition to Tactical Evacuation Care (TACEVAC).
Timely and effective communication with the casualty, other medical and nonmedical first responders, unit tactical leadership, and the evacuation system is critically important in ensuring that casualties get the lifesaving care they need.
Communicate with the casualty as part of your assessment to encourage and reassure them and to explain the care being given. Being physically wounded may generate significant anxiety and fear above and beyond the psychological trauma of combat. Talking frankly with the casualty about their injuries and offering reassurance by describing the treatments being rendered, emphasizing that everything possible is being done on their behalf, and that they will be well taken care of will help counter their anxiety. Be honest about the injuries sustained but maintain a positive attitude about rescue and treatment. Talking with the casualty helps assess their mental status, while talking through procedures helps maintain both your own confidence and the casualty’s confidence in you.
Communicate with other nonmedical and medical first responders to coordinate and direct care.
Communicate as soon as possible with unit tactical leadership and keep them updated. They need both tactically relevant and casualty information in order to continue the fight and coordinate evacuation. For example, tactical leadership may need to know:
- How many casualties were inflicted?
- Who is down as a casualty?
- Can the casualty still fight?
- Has the enemy threat been eliminated?
- Are weapons systems down or fields of fire not covered because the unit has taken casualties?
- Is it necessary to have others fill in the casualties’ fighting positions or to move the casualties?
Communicate with evacuation assets via 9-Line MEDEVAC request and MIST report (when appropriate) to provide number, type, priority, and status of casualties and evacuation equipment needed to inform coordination and prioritization of evacuation. Remember it is important to document casualty assessment and treatment on the DD Form 1380 Tactical Combat Casualty Care (TCCC) card, keep the card updated as the casualty status changes throughout the TFC phase, and ensure it is handed off with the casualty in the transition to Tactical Evacuation Care.
Every Service member should be able to initiate a medical evacuation request. Depending on the tactical situation, mission requirements, and unit standard operating procedures the tactical evacuation (TACEVAC), options may involve dedicated evacuation resources with medical capabilities (MEDEVAC) or could involve other transportation assets not dedicated to casualty movement but called on as vehicles of opportunity to support casualty evacuation (CASEVAC).
CASEVAC is the unregulated movement of casualties from the point of wounding to the first point of surgical care (Role 2 Forward Surgical Team or Role 3 Combat Support Hospital). CASEVAC platforms are typically armed tactical assets that bear no Red Cross markings. These may be aircraft, vehicles, or maritime vessels of opportunity.
This video demonstrates an example of a 9-Line MEDEVAC request followed by a MIST report.
Remember that the 9-Line MEDEVAC request communicates with the evacuation system (Evacuation Coordination Cell) to arrange for TACEVAC. The MIST report communicates medical information with medical providers on the evacuation asset and/or the receiving medical facility (as applicable) and relays mechanism of injury, injuries sustained, signs/symptoms, and treatments rendered to better prepare them to receive and continue care of the casualties.
Remember that when you request a medical evacuation, you aren’t directly coordinating with medical providers, but are explaining your evacuation requirements with someone who coordinates air asset movements. Although they still require some general information about the status of the casualty, much of the information that they need to coordinate evacuation is not clinical and relates to logistical and operational issues. Before initiating an evacuation, collect all of the information you will need, and when calling in, be sure to follow all appropriate and mandated communication protocols and guidance.
The North Atlantic Treaty Organization (NATO) doctrinal system specifies 3 evacuation categories (Urgent, Priority, and Routine). This system of casualty prioritization was adopted and used for requesting evacuation during the conflicts in Iraq and Afghanistan. The Department of Defense’s (DoD) Joint Trauma System and Committee on Tactical Combat Casualty Care (CoTCCC) also endorse this simplified system of casualty prioritization.
Determining the evacuation categories of the casualties is arguably the hardest part of the MEDEVAC request process. It is often difficult to estimate how stable a casualty might be after appropriate initial TCCC treatment has been provided.
Evacuation category determinations for casualties may be done by medics but is often done by nonmedical personnel who are initiating the MEDEVAC request.
Current US MEDEVAC doctrine describes 3 evacuation categories:
Urgent (Category A)
Evacuation within 2 hours, denotes a critical, life-threatening injury. Suggestions for different injury patterns in this category are:
- Significant injuries from a dismounted IED attack
- Gunshot wound or penetrating shrapnel to chest, abdomen, or pelvis
- Blunt chest, abdominal, or pelvic trauma with suspected non-compressible hemorrhage
- Ongoing airway difficulty
- Ongoing respiratory difficulty
- Unconscious casualty
- Known or suspected spinal injury
- Hemorrhagic shock
- External bleeding that is difficult to control
- Extremity injury with absent distal pulses
- Moderate/severe TBI
- Burns greater than 20% TBSA
Priority (Category B)
Evacuation within 4 hours, serious injury. Suggestions for different injury patterns in this category are:
- Isolated, open extremity fracture with bleeding controlled
- Extremity injury with a tourniquet in place
- Penetrating or other serious eye injury
- Significant soft-tissue injury without major bleeding
- Burns of 10% to 20% TBSA
Routine (Category C)
Evacuation within 24 hours, mild to moderate injury. Suggestions for different injury patterns in this category are:
- Concussion (mild TBI)
- Gunshot wound to extremity - bleeding controlled without tourniquet
- Minor soft-tissue shrapnel injury
- Closed fracture with intact distal pulses
- Burns of <10% TBSA
A--> Urgent evacuation within 2 hours.
B--> Priority evacuation within 4 hours.
C--> Routine evacuation within 24 hours.
Remembering the “A, B, C’s of evacuation” will help you to classify casualties. Category A = Life-Threatening; Category B = Serious Injury; and Category C = Mild to Moderate Injury.
Any threat to the casualty's Airway, Breathing, Circulation (including significant burns), and mental status will be classified as a Category A.
Category B casualties need to see a doctor as soon as possible but do not have an immediate threat of losing their lives.
Routine casualties are classified as Category C. These casualties are injured and need medical care, but they can wait longer than category A and B casualties.
Note that these are examples only and the evacuation category of a specific casualty may need modification based upon the findings during assessment in the Tactical Field Care phase.
Also, remember to reassess casualties often as their condition can change mandating a change in prioritization.
MIST reporting was instituted as a standard part of the MEDEVAC request during Operation Enduring Freedom in Afghanistan. Although not a formal part of the NATO and US standard MEDEVAC request, MIST reporting has become a norm in combat theaters. The MIST report follows the MEDEVAC request and transmits additional medical information to the receiving medical treatment facility and/or providers on the evacuation platform and may be required by theater/unit/commander policy.
The MIST report consists of the following:
- M - A brief description of the mechanism of injury (IED, GSW, blast, rollover vehicle crash, fall, etc.).
- І - A brief description of the injuries sustained starting with the most serious first. Highlight life-threatening injuries (bilateral lower extremity amputations, tension pneumothorax, etc.).
- С - Vital signs or significant symptoms (BP 90/palp, difficulty breathing, etc.).
- Т - Treatments rendered (tourniquets applied with bleeding controlled, blood given, ketamine 50 mg IM, etc.).
PDF 9-Line MEDEVAC and MIST Preparation Skill Card
Over-categorization, the tendency to classify a wound or injury as being more severe than it actually is, has been a problem both historically and in current operations. Proper classification is needed to ensure that casualties in greatest need are evacuated first and receive the lifesaving care they need in an appropriate timeframe. Over-categorization puts casualties, evacuation assets, and the overall mission at risk when evacuation efforts are inappropriately prioritized despite asset constraints and risk.
These “pearls of wisdom” are designed to help the corpsman or combat medic avoid over-categorization and determine the true urgency for evacuation. They assume that the decision is being made 15-30 minutes after wounding. They also assume that care is being rendered in accordance with the TCCC Guidelines. These considerations are most important when there are tactical or other constraints on evacuation and casualty evacuation must be prioritized. They are just rules of thumb.
Timely and effective communication with the casualty, other medical and nonmedical first responders, unit tactical leadership, and the evacuation system is critically important in ensuring that casualties are reassured, other responder care is coordinated, unit leadership has situational awareness and can assist with coordinating evacuation, and the evacuation system/assets have the information needed to appropriately prioritize and support casualty evacuation needs.
Casualty evacuation is requested using the 9-Line MEDEVAC request and MIST formats.
The 9-Line MEDEVAC request provides the number, type, priority, and status of casualties and evacuation equipment needed to inform coordination and prioritization of evacuation.
The MIST report (when appropriate) is used to ensure that the evacuation assets and receiving medical facilities have the medical information needed and are prepared to support the casualty’s needs.
Determining the evacuation categories of the casualties (prioritization) is arguably the hardest part of the MEDEVAC request process, as it is often difficult to estimate how stable a casualty might be after appropriate initial TCCC treatment has been provided.
US MEDEVAC doctrine describes 5 evacuation categories.
- URGENT--> Must be evacuated in less than 2 hours to save life, limb, or eyesight.
- URGENT SURGICAL--> Must be evacuated to the nearest surgical unit in less than 2 hours to save life, limb, or eyesight.
- PRIORITY--> Must be evacuated in less than 4 hours or could deteriorate to urgent.
- ROUTINE--> Must be evacuated in less than 24 hours.
- CONVENIENCE--> Evacuation is not a medical necessity.
But in practice, prioritization is often simplified using the 3 NATO categories.
- URGENT (A)--> Needs evacuation within 2 hrs.
- PRIORITY (B)--> Needs evacuation within 4 hrs.
- ROUTINE (C)--> Needs evacuation within 24 hrs.
Remembering the “A, B, C’s of evacuation” will help you to classify casualties. Category A: Life-Threatening, Category B: Serious Injury, and Category C: Mild to Moderate Injury.
To close out this module, check your learning with the questions below (answers under the image).
Check on learning
Who should a combat medic/corpsman communicate with during the Tactical Field Care phase of care?
- The casualty
- Other medical and nonmedical responders
- The tactical leadership
- The evacuation system
Which lines of a MEDEVAC must be transmitted for an asset to be launched?
Lines 1–5 are enough information to initiate a MEDEVAC depending upon pre-planning and coordination between tactical and evacuation units. Lines 6-9 can be transmitted while the evacuation asset is en route.
What information does the MIST report contain?
- Mechanism of injury
True or False? A combat casualty with 25% TBSA burns would be evacuation category A?
True. If the burns were less than 20% but more than 10% it would be Category B.
You can discuss this material on the TSSS forum