TCCC Care Under Fire

Your immediate priority is survival—yours and anyone nearby. If you are in an active threat situation (gunfire, explosion, civil unrest), you cannot help anyone if you are hit. Immediately move to hard cover (concrete wall, engine block, heavy furniture) rather than soft cover (drywall, thin doors). Take return action if safely possible: retreat, barricade, or use nearby objects as barriers. Only once you are in a defensible position can you assess casualties around you. This phase mirrors military "Care Under Fire"—the goal is to stop the threat or put distance between yourself and danger.

Do not approach an active threat to render aid. Wait for law enforcement or until the immediate threat is neutralized.

Extremity bleeding (arms, legs) is the #1 preventable death in civilian mass casualty events. The moment you reach a casualty, scan for spurting blood or heavy flow from limbs. If found, apply a high tourniquet (Combat Application Tourniquet, CAT, or equivalent) 2–3 inches above the wound, or higher if the wound is very proximal. Tighten until bleeding stops completely and the tourniquet is painfully tight—this is correct application. Do not second-guess tourniquet use; the risk of limb loss is far lower than the risk of death from hemorrhage. Write the application time on the tourniquet or casualty's skin with marker or pen if available. This step takes 10–15 seconds and is your highest-priority intervention.

Apply tourniquets aggressively. Waiting to see if direct pressure works costs precious minutes in active threat scenarios. Modern evidence supports early tourniquet use.

Once tourniquet is applied (or if no extremity bleeding is found), move the casualty out of the direct line of fire. Use the drag technique: grab under the armpits or use a clothing drag if the casualty is wearing a jacket, and pull them behind cover. This is faster than carrying and protects both you and the casualty from further injury. If there are multiple casualties, prioritize those with massive bleeding or airway compromise. Position the casualty on their back in a sheltered location where you can continue assessment. If the threat remains active, keep the casualty low and out of sight. Once sheltered, you transition to Tactical Field Care—a more thorough assessment phase.

Do not linger in the open to help. A second casualty (you) helps no one. Move quickly and decisively.

With the casualty in shelter and immediate hemorrhage controlled, perform the MARCH assessment: Massive hemorrhage (already addressed), Airway, Respiration, Circulation, and Hypothermia. Check airway: listen for breathing, look for obstruction (blood, vomit, tongue). If the airway is blocked and the casualty is unconscious, perform a head-tilt chin-lift or jaw-thrust maneuver. Remove visible obstructions carefully. Check respiration: note the rate and effort. Normal breathing is 12–20 breaths per minute. If respiratory rate exceeds 30 or is very shallow, this indicates severe shock or tension pneumothorax. If the casualty is not breathing, begin rescue breathing if trained. If you observe severe difficulty breathing after penetrating chest trauma, prepare for chest seal application.

If the casualty is unconscious with no gag reflex, position on their side (recovery position) to prevent aspiration if vomiting occurs.

Continue MARCH assessment: check for additional bleeding sources. Perform a rapid visual sweep for wounds on the chest, abdomen, and neck. For any wound with significant bleeding not controlled by tourniquet, apply direct pressure with a sterile or clean cloth and hold for at least 3 minutes. If bleeding persists, apply a second dressing over the first (do not remove the first); this avoids breaking a forming clot. For penetrating chest wounds (entry or exit), cover with a chest seal (commercial or improvised: plastic wrap and tape on three sides, leaving one corner unsealed to allow air escape). Chest seals prevent tension pneumothorax and allow the casualty to breathe. Reassess breathing after sealing. For abdominal wounds, cover with a dressing but do not apply direct pressure if organs are eviscerated; instead, gently cover the area and keep the casualty calm.

If a casualty develops sudden respiratory distress and has a penetrating chest wound, the seal may have failed or tension pneumothorax has developed; unseal briefly to release pressure if trained.

If you are trained in IV or IO (intraosseous) access, and the casualty shows signs of shock (pale skin, weak pulse, confusion, rapid breathing), establish access and administer fluids if available and protocols permit. In civilian contexts, IV access may be limited unless you are a trained paramedic or in a structured group setting (workplace, school, event). If fluids are available, administer via IV or IO if trained; if not, position the casualty supine (flat on back) to maximize blood flow to vital organs and cover with a blanket to prevent hypothermia. Monitor the pulse: check for femoral pulse at the groin or carotid at the neck. If no pulse is felt and the casualty is unresponsive and not breathing, begin CPR if trained and conditions permit. Document the casualty's condition and any interventions performed.

Do not attempt IV access if you are untrained. Focus on tourniquet and direct pressure, which are the proven life-savers in civilian mass casualty events.

As law enforcement, paramedics, or professional rescuers arrive, prepare the casualty for evacuation. Ensure tourniquets are visible and marked with the time applied. Communicate your interventions clearly: "Tourniquet applied to left leg at 2:15 p.m., bleeding controlled. Airway clear, breathing at 22 per minute. Penetrating chest wound sealed. Possible shock—no IV access available." Keep the casualty warm and reassure them. If multiple casualties are present, use START (Simple Triage and Rapid Treatment) triage: immediate (severe breathing difficulty, uncontrolled bleeding, unresponsive), delayed (moderate injuries, conscious), minor (walking wounded), expectant (profound injuries, no vital signs). Prioritize immediate cases for evacuation. Continue monitoring the casualty until professional medical personnel assume care. Your role shifts from emergency responder to information provider and comfort giver.

Do not move a casualty during active threat. Wait for all-clear from law enforcement. If you must move, communicate urgently with others to prevent friendly-fire incidents.