Tactical Combat Casualty Care for SOF Operators

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Afternoon Two
Real World Tactical Scenarios Lessons learned
Scenarios (By audience) Exam and Review Course
feedback
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Tactical Casualty Scenarios

• If your combat trauma management plan doesnt
  work for the tactical situation, then for SOF
  combat medics - it doesnt work.
• Dont want to trade one set of rigid guidelines
  for another
• Scenario-based planning

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Urban Warfare Scenario
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Urban Warfare Scenario

• 16 man Ranger team
• 70 foot fast rope insertion for building assault
• One man misses rope and falls
• Unconscious
• Bleeding from mouth and ears
• Taking fire from all directions from hostile
  crowds

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The Battle of Mogadishu

• Most US casualties in a single firefight since
  Vietnam
• US casualties 18 dead, 73 wounded
• Estimated Somali casualties 350 dead, 500 wounded
• Battle 15 hours in length

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Mogadishu Complicating Factors

• Helo CASEVAC not possible because of crowds,
  narrow streets and RPGs
• Vehicle CASEVAC not possible because of ambushes,
  roadblocks, and RPGs
• Gunfire support problems non-combatants, cover
  from buildings

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Care under Fire

• Return fire?
• Move patient to cover right away or wait for long
  board?
• How should he be moved?
• Intubation?
• IV fluids?
• Urgency for evacuation?

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Wear your body armor!
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Shrapnel Stopped by Strike Plate
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Even though it only caught the edge, the plate
stopped this piece of shrapnel
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Wear your tactical eyewear!
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EYE Protection WORKS!
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NO eye protection
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Eye Protection
No Eye Protection
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Bilateral Eye Enucleation (Removal)
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Authorized Ballistic Protective Eyewear Systems
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Questions?
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Scenario Discussions

• Break into groups of 5 1 medical person to lead
  discussion
• You are the one administering/in charge of
  treatment
• 1 operator per scenario
• 10 minutes per scenario

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Mogadishu - Scenario 7 Helo Hit by RPG
Round

• Hostile and well-armed (AK-47s, RPG) urban
  environment
• Building assault to capture members of a hostile
  clan
• In Blackhawk helicopter trying to cover helo
  crash site
• Flying at 300 foot altitude

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Mogadishu - Helo Hit by RPG Round (cont)

• Left door gunner with 6 barrel M-134 minigun
  (4000 rpm)
• Hit in hand by ground fire
• Another crew member takes over mini-gun
• RPG round impacts under right door gunner

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Mogadishu - Helo Hit by RPG Round (cont)

• Windshields all blown out
• Smoke filling aircraft
• Right minigun not functioning
• Left minigun without a gunner and firing
  uncontrolled
• Pilot
• Transiently unconscious - now becoming alert

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Mogadishu - Helo Hit by RPG Round (cont)

• Co-pilot
• Unconscious - lying forward on helos controls
• Crew Member
• Leg blown off
• Lying in puddle of his own blood
• Femoral bleeding

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Mogadishu - Helo Hit by RPG Round (cont)

• YOU are the guy providing care
• What do you do first?

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Afghanistan
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SEAL Casualty - Afghanistan

• August 2002
• Somewhere in Afghanistan
• SEAL element on direct action mission
• Story of the casualty as described by the first
  responder

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SEAL Casualty - Afghanistan

• There were four people in my team, two had
  been shot. Myself and the other uninjured
  teammate low crawled to the downed men. The man I
  came to was lying on his back, conscious, with
  his left leg pinned awkwardly beneath him. He was
  alert and oriented to person, place, time, and
  event. At that point I radioed C2 to notify them
  of the downed man.

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SEAL Casualty - Afghanistan

• Upon closer inspection, his knee was
  as big as a basketball and his femur had broken.
  The patient was in extreme pain and did not allow
  me to do a sweep of his injured leg. He would
  literally shove me or grab me whenever I touched
  his leg or wounds. I needed to find the entrance
  and exit wound and stop any possible arterial
  bleeding.

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SEAL Casualty - Afghanistan

• But there was zero illumination and he
  was lying in a wet irrigation ditch. So I
  couldnt see blood and I couldnt feel for
  blood.

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SEAL Casualty - Afghanistan

• We were also in danger because our
  position was in an open field (where the
  firefight had been) and I had to provide security
  for him and myself. So, I couldnt afford to turn
  on any kind of light to examine his wounds. I
  told him to point to where he felt the pain. He
  had to sort through his pains.

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SEAL Casualty - Afghanistan

• He had extreme pain in his knee and
  where his femur had been shattered as well as a
  hematoma at the site of the entrance wound
  (interior and upper left thigh). Finally, he
  pointed to his exit wound (anterior and upper
  left thigh). Again, I had no way of telling how
  much blood he had lost. But I did know that he
  was nonambulatory.

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SEAL Casualty - Afghanistan

• So I called C2 again. I gave him the
  disposition of the patient as well as a request
  for casevac, a corpsman, and additional personnel
  to secure my position and assist in moving the
  patient to the helicopter. I thought about moving
  the two of us to some concealment 25 meters away,
  but we were both really low in a shallow
  irrigation ditch. I felt safer there than trying
  to drag or carry a screaming man to concealment.

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SEAL Casualty - Afghanistan

• Between providing security and spending
  a lot of time on the radio I didnt get to treat
  the patient as much as I wanted to. I had given
  him a Kerlix bandage to hold against his exit
  wound. When he frantically told me that he was
  feeling a lot of blood, I went back to trying to
  treat him. I couldnt elevate his leg. To move it
  would mean hed scream in pain, which wasnt
  tactical.

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SEAL Casualty - Afghanistan

• There was just no way he would allow me
  to apply a pressure dressing to the exit wound
  even if I could locate it and pack it with
  Kerlix. So, I decided to put a tourniquet on him.

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SEAL Casualty - Afghanistan

• His wounds were just low enough on his
  leg to get the tourniquet an inch or so above the
  site. I had a cravat and a wooden dowel with 550
  cord attached to it to use as a tourniquet. I
  told him to expect a lot of pain as I would be
  tightening the cravat down.

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SEAL Casualty - Afghanistan

• At this point he feared for his life so
  he agreed. Once I got it tightened I had trouble
  securing it. The 550 cord was hard to get
  underneath the tightened cravat.

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SEAL Casualty - Afghanistan

• After over 5 minutes, the corpsman
  arrived along with a CASEVAC bird and a security
  force. Moving the patient was very hard. Four of
  us struggled to move him and his gear 25 meters
  to the bird. The patient was over 200 pounds
  alone and we were moving over very uneven
  terrain.

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SEAL Casualty - Afghanistan

• We wanted to do a three-man carry with
  two men under his arms and one under his legs.
  But again, his leg was flopping around at the
  thigh and couldnt be used to lift him.

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SEAL Casualty - Afghanistan

• The bird, (a TF 160th MH-60) had a 50-cal
  sniper rifle strapped down, which made it hard
  for us to get him in. It took us minutes to get
  him 25 meters into the bird. The corpsman went
  with my patient as well as the other downed man
  in my team and I went back to the op.

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Ambush In Afghanistan
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Ambush In Afghanistan

• Small U.S. military outpost in a village in
  Eastern Afghanistan
• Unpaved, rocky mountain road
• 2 vehicles moving in a routine convoy to visit
  nearby town and buy fuel
• Vehicle 1 - Two occupants
• Vehicle 2 - Three occupant
• No medics in convoy

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Ambush In Afghanistan

• Decision Point
• Should you wear seat belts in this type of a
  convoy?

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Ambush In Afghanistan

• Second vehicle struck by command-detonated IED
• Flipped over on its roof
• First car occupants uninjured

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Ambush In Afghanistan

• Decision Point for occupants of first vehicle
• Treat the casualties or establish security?

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Ambush In Afghanistan

• You are the doctor at the outpost about 500 yds
  away holding clinic for the local Afghan
  children.

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Ambush In Afghanistan

• You hear the explosion
• Receive call that there are 3 people dead
• ? other injuries
• Body armor and weapon are several minutes away in
  other direction
• Quick Reaction Force is gearing up

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Ambush In Afghanistan

• Decision Point
• What do you do?
• Get weapon and wait for QRF?
• Get weapon and move on foot to crash site?
• Grab trauma bag and move to crash site
  immediately?

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Ambush In Afghanistan

• Driver no seat belt
• Conscious
• Large facial laceration
• Severe nose pain and bleeding
• Neck pain
• No back pain

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Ambush In Afghanistan

• Interpreter seat belt
• Chipped tooth
• Foreign military person
• Large leg laceration bleeding heavily
• Trapped in car
• Moaning with pain
• Struggling to get out of the collapsed,
  overturned vehicle

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Ambush In Afghanistan

• Decision Point
• You are the driver of the ambushed vehicle.
• Should you make the person stay in the car?
• What to do next?

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Ambush In Afghanistan

• Driver helps extract injured passenger
• Doctor arrives on the scene a few minutes later
• Individual with leg laceration already taken by
  truck to village
• Treating the driver

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Ambush In Afghanistan

• Decision Point
• How to treat the injured driver?
• Long spine board?
• C-collar?
• Try to close facial wound?

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Ambush In Afghanistan

• Follow-up on the casualty that left the scene
• Brought back about 40 minutes later
• No respirations/HR
• Fixed and dilated pupils
• No obvious head injury (no Battles sign)
• No obvious step-offs in neck

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Ambush In Afghanistan

• Decision Point
• Should you start CPR?

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Ambush In Afghanistan

• Transport casualties to HLZ

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Questions?
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CQB Scenario

• A SOF element is moving on a high-value target in
  an urban environment
• The first two men in a 8-man train are shot by
  an individual with an automatic weapon while
  moving down a hallway.
• The attacker follows this burst with a grenade.

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CBQ Scenario (2)

• One operator is shot in the abdomen but
  conscious.
• The second casualty is shot in the shoulder area
  with severe external bleeding.
• The third operator is unconscious from the
  grenade blast.
• The attacker withdraws around a corner.

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CBQ Sceanrio (3)

• Tactical actions
• Medical considerations
• Abdominal wound
• Shoulder wound
• Unconscious casualty

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Tactical Combat Casualty Care

• Casualty scenarios in Special Operations usually
  entail both a medical problem and a tactical
  problem.
• Emergency action must address both problems at
  the same time.
• INCLUDE MEDICAL ELEMENT IN OPS PLANNING!

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Scenario-Based Planning

• Consider management plans for combat trauma to be
  advisory rather than directive in nature.
• Rarely will an actual tactical situation exactly
  reflect the conditions outlined using such
  scenarios.
• Need to go beyond a by the numbers mentality

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TCCC Objectives

• Treat the casualty
• Prevent additional casualties
• Complete the mission

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• Lessons from the Front
• Feedback from docs and medics based on their
  experiences treating casualties in OIF/OEF

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JDAM 1
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JDAM 2
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JDAM 3
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Ranger 1
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Ranger 2
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Ranger 3
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Ranger 4
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Ranger 5
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Ranger 6
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Ranger 7
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Ranger 8
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CASEVAC Doc in Iraq

• If you are in a SOF unit and you are shipping a
  wounded detainee for care ALWAYS send a
  security detachment to guard the detainee.

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TCCC in IRAQ

• The adoption and implementation of the
  principles of TCCC by the medical platoon of TF
  1-15 IN in OIF 1 resulted in overwhelming
  success. Over 25 days of continuous combat with
  32 friendly casualties, many of them serious, we
  had 0 KIAs and 0 Died From Wounds, while
  simultaneously caring for a significant number of
  Iraqi civilian and military casualties.

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TCCC in IRAQ (cont)

• This success should serve as a model for other
  conventional combat units throughout the army
  involved in Level 1 treatment.
• The principles of TCCC are well-researched and
  proven effective and should be the foundation of
  the treatment of battlefield casualties.
• CPT Michael Tarpey
• Battalion Surgeon 1-15 IN
• 20 January 2005

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The End
The End
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