This module discusses casualty preparation for evacuation during the Tactical Field Care (TFC) setting.
All Service Member and Combat Lifesaver training educates non-medical personnel about supporting the casualty evacuation preparation process. As a Combat Medic you will supervise that preparation process and be responsible for the transition of care from the Tactical Field Care setting to the Tactical Evacuation Care (TEC) phase.
There are eight cognitive and one performance enabling learning objectives in this module.
While focusing on identification of the important principles of preparing and staging casualties for evacuation you will also be learning about several related topics, to include the importance of pre-mission training, considerations for evacuation of a casualty with a suspected spinal injury, litter and evacuation equipment selection, and considerations for evacuation of ambulatory casualties. Additionally, the process of transitioning care to evacuation personnel and the responsibilities of tactical force personnel during the evacuation process will be discussed.
Afterward, you will demonstrate the preparation of a casualty for evacuation in the Tactical Field Care phase.
Proper preparation for evacuation will help to ensure a smooth handover to evacuation personnel. Keep in mind that the transition is challenging for several reasons. The tactical environment may be somewhat insecure, the environment may involve loud noise conditions (like under spinning helicopter rotor blades or at the tail of a fixed-wing evacuation aircraft), and the receiving asset may be moving slightly (like on small boats rocking back and forth in rough seas). A smooth transfer of care in these hectic environments is facilitated by well-prepared casualties, preplanned procedures, rehearsals, and effective communication.
Although every tactical situation and set of casualties will dictate the way you prepare casualties for evacuation, there are some basic principles common to all of them that can guide your actions and ensure the best possible outcome for the casualty.
In most situations, the first thing you will do is prepare each casualty for evacuation. Some of the steps and individual tasks may be delayed until the staging phase, if the tactical situation mandates casualty movement prior to completion of preparation for every casualty, but usually the preparation is integrated into the last steps in the tactical trauma assessment and can be accomplished prior to movement. This is when many of the steps in the TCCC Guidelines are executed, to include securing the DD Form 1380, the loose ends of wraps, bandages, and hypothermia prevention materials, and tightening litter straps prior to movement.
Once the casualties are prepared, the next step is to stage them for evacuation. This might be done twice, once near the treatment area and again at the evacuation location, if the evacuation pick-up site is located at a distance from the treatment site and there is a delay in evacuation. This is also the time when instructions will be provided to casualties, in particular the ambulatory casualties, to reduce the workload on the evacuation team during the casualty pick-up process.
When the evacuation assets are approaching, it is vital to secure the evacuation zone using the tactical forces personnel provided to you by the local unit leadership.
And lastly, when the assets arrive, the casualties must be properly loaded, following the guidance of the incoming evacuation personnel. As a Combat Medic, you will be responsible for the transition of care from your team in Tactical Field Care to the receiving evacuation team as the casualty enters the Tactical Evacuation Care phase.
Staging typically occurs in close proximity to the evacuation site, and if not co-located with the treatment site, the casualties are moved there in advance. Although you do not want to have the asset waiting for the arrival of the casualties, you also do not want to have the casualties arrive too soon if the environment is not ideal for waiting long periods of time.
Remember, when moving casualties over long distances, tourniquets, dressings, IV lines, or other interventions should be checked periodically to ensure they are intact and functioning. You should definitely do this upon arrival at the staging site, if not along the way.
In transit and once at the staging area, casualties should be protected as much as possible from environmental elements (like the sun, rain, wind, or cold) and observed for signs of hypothermia or dehydration.
At the site, the casualties should be arranged so that they can be loaded in sequence, according to their movement priority and clinical status. This may be dictated by unit procedures, or it may be provided by the evacuation platform personnel. In general, when feasible, ambulatory and routine casualties are loaded first, followed by priority casualties, and urgent casualties are loaded last. This allows for urgent casualties to have the least amount of time on the evacuation platform, and more importantly, to be the first off of the asset once it arrives at its destination.
Once the evacuation asset arrives, the personnel responsible for loading casualties will dictate the order of casualty movement, regardless of the way the casualties were arranged by the ground medical team.
As you can imagine, several members of the unit are involved in choreographing a successful casualty evacuation. If the first time that unit members are involved in this process is during an actual evacuation, there is a significant risk that the team will not function well and the evacuation process will be delayed or the transition of care will be less than optimal, which could result in an adverse clinical outcome. So, it is important that pre-mission rehearsals be part of every unit’s training, both at home station and down-range.
These rehearsals not only involve understanding the primary role each unit member will be expected to perform, but cross-training unit members so that they can assume the duties of one of the other members, should that member become a casualty and need to be replaced. It is not enough to talk through the process, it is essential to run dress rehearsals where unit members perform their functions under your supervision. Carrying out the individual tasks uncovers problems that can be easily resolved, and builds confidence in your unit personnel.
Another part of the pre-mission process is preparing evacuation equipment. At the onset of a deployment, most equipment is usually stocked and functional; but that should still be confirmed prior to departure from home station and after arrival. Once deployed, not only do you need to ensure equipment is in working order, you need to ensure all required equipment is present, as prior missions may have used assets that were not properly resupplied. This emphasizes why it is important to ask for equipment replacement during the evacuation request process. Also, key members of the unit need to know where the equipment will be located when out on a mission, and how to access it, as you will not have time to search for the equipment when you are providing or supervising casualty treatment.
Understanding that each situation is unique, there are some basic measures that should be followed for all evacuation preparation scenarios. The TCCC Guidelines outline the critical actions that should be followed. Although usually handled by unit leadership and fellow team members, ensure casualty’s weapons and equipment are secured, as appropriate.
Complete and secure the DD Form 1380 to the casualty. Some hypothermia shells or patient transport covers have a transparent pouch where you can put the DD Form 1380, but many do not. Options for securing it to the patient include attaching it to their wrist or other body parts if there is a band or taping it to them or their packing materials. Remember that the goal is to not have the casualty and their DD Form 1380 separated as they go through their continuum of care. So, however you secure it, make sure it will stay with the casualty.
Secure all loose ends of bandages and wraps. Loose treatment interventions pose risks for the casualty, the responders, and even the evacuation assets. For the casualty, a loose wrap or exposed tourniquet windlass can be caught on individuals working around the casualty or on the evacuation platform and be compromised, requiring that the intervention be reassessed and treated again, potentially worsening the clinical situation or delaying evacuation. Responders and personnel working around the casualty can get caught by loose interventions and hurt themselves, for example by tripping over the loose wraps. And anything that isn’t secure has the potential for breaking loose and can fly free, particularly in rotor wash or at the tail of an aircraft, both creating a projectile that can hurt personnel and debris that can damage the evacuation asset.
Secure hypothermia prevention wraps, blankets, and straps. Similar to the prior discussion, the actual casualty wraps can be a problem for the very same reason. But even if they don’t break free and create those problems, if they are not properly secured the hypothermia prevention measures will not be effective. The wraps need to retain any heat being produced by the casualty or their heating device, which won’t happen if they are loose.
Secure litter straps as required. Consider additional padding for long evacuations. Litter straps are commonly loosened to allow access to the casualty for reassessment purposes, and occasionally they are not re-tightened afterward, either for easy access or casualty comfort. However, when transporting the casualty and while in the evacuation asset, this can be a significant safety hazard. Be sure to check all straps, and ensure each casualty has at least two straps. Litters are, by their very nature, uncomfortable. For short periods this is usually tolerated fairly well. But for prolonged waiting periods and long evacuation, this can add to casualty pain and stress and adversely affect their outcome. Whenever possible, add padding to provide casualty comfort, even if the casualty is not complaining of being uncomfortable.
The TCCC Guidelines highlight that cervical spine stabilization is not necessary for casualties who have sustained only penetrating trauma. Several studies and guideline papers from professional societies mirror that guidance. And because of the tactical considerations and treatment priorities in the battlefield environment, spinal immobilization, as a rule, is not a primary objective of Care Under Fire or Tactical Field Care phases.
However, as the casualty transitions from TFC to TEC, there may be time and a permissive environment to address suspected spinal injuries. If the casualty is a victim of blunt trauma and experiencing spinal pain, has visible swelling or hematomas along the spine, or is experiencing radiating pain or unexplained loss of sensation in their extremities, spinal injury may be suspected.
If suspected, a rigid litter that provides adequate support to help protect the spinal cord from sustaining secondary injury should be used, if at all possible. Long spinal boards and classic spinal immobilization materials are usually not available. If appropriate, they can be requested when calling in the 9-Line. If the injury involves the C-spine, a cervical collar can be improvised from a malleable splint or other material and applied to the casualty before moving. But if the suspected injury is at a lower level, the rigid litter with firmly applied straps to prevent undesirable movement during casualty transport should be adequate.
During the transition of care to the receiving evacuation team, the suspicion of a spinal injury and any measures you have taken should be communicated.
The types of litters and evacuation equipment you have access to will be determined by a combination of your unit standard operating procedures and the deployed mission environment. Ideally, you will have access to a few different assets, as each of them has advantages and disadvantages based on the tactical environment (terrain, weather, hostile threats) and the evacuation assets (air ambulance, air asset of opportunity, ground vehicles).
Evacuation equipment (like litters & packaging materials) should be prepared by other unit personnel while treatment is rendered by medical personnel. Do not delay getting casualties onto litters as it is easier to prevent hypothermia when casualties are off the ground and casualty movement is facilitated by being on a litter.
Train on the equipment your unit supplies, but make every effort to expose yourself to, and even train on, other types of equipment, as you may very well encounter them when deployed. It is definitely an advantage to have equipment familiarity prior to using them in an operational setting.
The quad-fold Talon II® litter is perhaps the most common litter currently being used. Once set up properly, it has rigid poles, and the grips help make it advantageous for transporting a casualty in rough terrain. It has integrated litter straps and the mesh material makes it easy to clean and useful in decontamination scenarios. Also, the Talon II litter has collapsible handles and will fit into standard H-60 MEDEVAC platforms, whereas some of the other litters like the Raven 90C® bi-fold litter do not fit properly.
Skedco™ litters are commonly used tactical litters in light infantry and airborne units. They do not have rigid poles, so carrying them by their handles is not easy and can be tiresome over distances. However, they do function well as drag or slide devices, and if the terrain is smooth, they can be easily pulled by one or two responders, being cautious not to let them slide out of control when going downhill. They are often used to carry gear and ammunition into the mission and carry casualties out. And properly rigged, they can be hoisted into a helicopter or Osprey, although not all versions are hoist-certified.
The “Army standard litter” is another option for a tactical litter. It does not have preinstalled litter straps, so these will need to be carried on the mission as well. Many countries have variations of this litter, with rigid poles and canvas material liners, so it is common to see these in multinational operations. There is wide variability in what is considered NATO-standard, and not all NATO-standard litters will fit into US evacuation assets.
The Stokes litter may be used by rescue units but is not typically carried by ground combat units. It is a basket litter, sometimes made of wire mesh and metal materials, and sometimes plastic. The casualty can usually be placed inside the basket in a Skedco litter, but it will not accommodate a rigid pole litter and might require casualties be transferred if the evacuation platform requires the use of this litter. Stokes litters can be dragged by two rescuers, if necessary, but can also be carried by four.
In the absence of a dedicated litter, it is possible to fashion improvised litters. There are several techniques, but most involve selecting rigid pole-like materials and then using ponchos, poncho liners, blankets, field jackets, or other field-expedient materials to form the bed of the litter. A rigid transport platform, like a door, is also an option if properly padded. Casualty safety is important, so care must be used to ensure any improvised litter will be able to support the casualty’s weight, be relatively easily carried by a litter team, and not risk significant casualty movement during transport.
Choosing a litter may be based solely on equipment availability; but if multiple options are available, then base your decision on a combination of the terrain and tactical considerations, the unit personnel you have to support casualty movement, and the evacuation asset you anticipate using.
The TCCC Guidelines highlight the requirement to provide instructions to ambulatory patients as needed. As part of the casualty preparation phase or the evacuation staging phase, depending on the situation, time should be taken to address ambulatory casualties and how they will be handled during the evacuation process.
Once you have determined that a patient is able to ambulate, it is important to assess their capabilities to assist in the evacuation process, either through being self-sufficient or perhaps even supporting others. For example, are they capable of providing security? Could they help lift a littered patient? Or can they help watch out for and/or care for other ambulatory casualties?
If they are able to help with the evacuation process, provide them clear guidance on the role you want them to perform and assign an uninjured unit member to be their point-of-contact (POC) if the casualty feels their situation is changing and they can no longer help out. Have that POC keep an eye on them, too, as they should be reassessed for potential changes in mental status or capabilities from time to time.
Disoriented or visually impaired casualties require supervision to be evacuated, even as ambulatory casualties. This can be done by a non-medic and done in groups if there are several. When they need to move as a group, like when approaching the evacuation platform, they should line up and each place their hand on the shoulder of the casualty in front of them and follow their lead, with the lead casualty being someone without visual impairment or disorientation (another casualty, a Combat Lifesaver or other uninjured non-medic).
To reduce the workload on the supporting medical personnel, instruct ambulatory casualties on repeatedly checking their own wounds and dressings to ensure that bleeding remains controlled and there isn’t a change in their status, advising them about who to notify if there is a change.
Tactical force personnel are responsible for identifying, securing, marking, and preparing the evacuation site (helicopter landing zone, ambulance loading point, etc.) in advance of the arrival of evacuation assets.
Unit standard operating procedures will likely govern security at the evacuation point, and the entire unit, including medical personnel, should be prepared to support unit leadership in that process. The potential for exposing the unit and the evacuation team to hostile forces is significant and maintaining security is vital to the success of the evacuation process.
Tactical leadership will define the security measures and inform medical personnel of the parameters that will guide their casualty staging plan. Throughout the process, leadership is multi-tasked with ensuring the safety of both casualties and the tactical personnel who are moving the casualties and maintaining awareness of potential hostile threats that could impact the success of the evacuation.
A critical step in casualty management is successfully transitioning care from one provider to another. In the civilian setting, there is overwhelming evidence that less-than-ideal hand-offs and inadequate communication of patient information lead to poor clinical outcomes. Despite the fact that there are fewer military-based studies, anecdotal evidence from battlefield casualty care management transfers indicates that this is true in the tactical environment, as well.
There are several environmental factors that can negatively impact the transition of care and sharing of information in the tactical environment. The threat of hostilities in an exposed location leads to a requirement to minimize the time on ground during an evacuation by air assets, as does the fact that fuel levels may be limited. The noise and rotor or engine wash can reduce eye contact and hearing thresholds, leading both parties to look for abbreviated means of communication. The casualty evacuation process is not part of the unit’s mission objectives and there is pressure to transition back to normal operations as soon as possible. All of these things, and more, can have a negative impact on the transition of care if not mitigated properly.
One very important tool to help provide adequate casualty information is the make sure that the DD Form 1380 is fully completed, up-to-the-minute, and accompanies the casualty throughout their journey.
That said, there are subtle findings and experiences from assessing and treating the casualty that are more appropriately passed along in a verbal transition of care. So, you should be prepared to provide a MIST (Mechanism, Injuries, Signs, Treatment) report, focusing on those aspects that might not be self-evident from the DD Form 1380, including your sense of the casualty’s stability for evacuation.
As mentioned, there are several factors that might be obstacles to this in the tactical situation, and you should be prepared to address those as they arise. Some potential ways to do that include:
This video will review the basic steps a Combat Medic should follow when preparing a casualty for evacuation.
During this module, we went over the key concepts you will need to know to prepare casualties for evacuation.
In addition to having an overview of the process of preparing and staging casualties for evacuation, we talked about several areas in more depth, to include: the importance of pre-mission training, litter and evacuation equipment selection, critical actions in preparing casualties, considerations for evacuation of a casualty with a suspected spinal injury, and considerations for evacuation of ambulatory casualties. Additionally, the process of staging casualties, the responsibilities of tactical force personnel during the evacuation process, and effective transition of care to evacuation personnel were discussed.
And in the end, you demonstrated the preparation of a casualty for evacuation in the Tactical Field Care phase.
To close out this module, check your learning with the questions below (answers under the image).
Answers
Why is it important to perform pre-mission rehearsals of preparation for evacuation?
If the first time that unit members are involved in this process is during an actual evacuation, there is a significant risk that the team will not function well and the evacuation process will be delayed or the transition of care will be less than optimal, which could result in an adverse clinical outcome. These rehearsals not only involve understanding the primary role each participant will be expected to perform, but cross-training unit members so that they can assume the duties of one of the other members.
What goes into selecting a litter?
Choosing a litter may be based solely on equipment availability; but if multiple options are available, then base your decision on a combination of the terrain and tactical considerations, the unit personnel you have to support casualty movement, and the evacuation asset you anticipate using.
Name three critical actions in preparing a casualty for evacuation.
How should you arrange casualties when staging them at the evacuation site?
At the site, the casualties should be arranged so that they can be loaded in sequence, according to their movement priority and clinical status. This may be dictated by unit procedures, or it may be provided by the evacuation platform personnel. In general, when feasible, ambulatory and routine patients are loaded first, followed by priority casualties, and urgent casualties are loaded last.
You can discuss this material on the TCCC forum
