Legacy Advanced Medical & TCCC (A3 KAT)

Pre-hospital Trauma Life Support & Tactical Combat Casualty Care

This quick guide will work from least to most difficult wounds, and has been tailored to our most current, in-house, Coalition brand of ACE advanced medical.

Duties of TCCC for Combat Medics:

Identify wounded personnel in your fireteams of responsibility
Conduct rapid and efficient assessments of casualties and triage
Stop Bleeding, distribute bandages, utilise CLS as support
And administer advanced treatments and meds only after taking vitals

Casualty Triage

In most cases you'll have more than one casualty - thus it's important to determine which needs treatment and which can treat themselves. Some green recruits may continue on mission despite bleeding, worsening their wounds, so dictating to them what needs to be done becomes important. In some cases ask the nearby CLS to act on this in support of your triage efforts.

Categories of Wounded: Part of Triage is to categorise your wounded and relay this information via medical net or squad net to the appropriate parties. If you are to liaise with platoon medical officer, med net is 343-Chan 16, otherwise use the applicable 148 Squad Net. These sorts of categories are also used on line 3 of a conventional CASEVAC 9-Line, though we dont use that in Coalition because we arent that spergy. Proscribed categories of wounded allow personnel to prioritise worse wounded over those least likely to die on arrival at a Casualty Collection Point (CCP) or Field Hospital (FH).

Cat 1 (or Cat Alpha) - Urgent -> Likely still bleeding, several wounds and sub 50 systolic pressure, needs treatment immediately. Needs to be evacuated immediately after stabalisation.
Cat 2 (or Cat Bravo) - Urgent Surgical -> Was Cat 1 urgent but is now stable, several wounds and sub 80 systolic pressure, needs surgery soon or condition will deteriorate. Likely requires evacuation very soon.
Cat 3 (or Cat Charlie) - Priority -> perhaps two wounds, may be ambulatory, sub 100 systolic pressure, needs surgery but can be delayed during triage. Could be treated in the field without need for evacuation.
Cat 4 (or Cat Delta) - Routine -> walking wounded, one to two wounds, systolic pressure between 120 and 90, may need additional help but can hold. Almost always treated in the field.

There is a Cat 5, (Cat Echo) "Conventional" but we wouldnt really use that.

Once you've isolated the injured party, stop the bleeding.

Different types of bandages:

Packing Bandages - For most small to medium velocity wounds - use a packing bandage, follow with elastic if its still light red.

Elastic Bandages - Use if the casualty suffered an avulsion (a chunk of flesh torn from them).

Quickclot - If the casualty is hemorrhaging from a large velocity wound, consider using quickclot for its hemostatic properties, followed by a packing bandage and/or an elastic bandage.

Tourniquets - Are present in all IFAKs (individual first aid kits) and may be used to decrease bleeding from an extremity. After 15min of continual use they begin to cause pain to the wearer.

Note: it is advised you treat wounded in cover, or away from combat, yet in some cases this is not possible. If they have a significant wound to their leg, they may not be able to run, so treating such an injury is often the right call, even in an open area where the enemy may fire on you as they are otherwise not ambulatory.

Patient Assessments

Note: once the bleeding has been dealt with and/or the casualty has been displaced to a safe area to treat them, we need to determine vitals. Be aware that some wounds may reopen in transport of the patient, or may re-open due to increased blood pressure, so advanced treatments determined after an assessment of vitals may require further bandaging.

Normal BP, Blood Pressure is 120/80 (systolic / diastolic) pressure - and normal heart rate (or pulse) is 80 bpm (beats per minute). These are the basic thresholds, vitals, we want to restore the casualty to these thresholds and maintain them for the duration of the mission.

|| Common BP abnormalities include; Hypotension - generally BP 90/60 and lower and Hypertension - threshold of 140/90 - though this is extremely uncommon. Additionally, unless you over-administer epinephrine, tachycardia, forms of atrial fibrillation and/or superventricular tachycardia dont happen. Medications are issued to regulate these heart rate and BP abnormalities.

Example:

For our example we'll treat an individual who suffered a gunshot wound to the chest, and an avulsion to the left arm from fragmentation.

The patient presents with these above-mentioned injuries. They've already placed a tourniquet on their left arm. This is a Category 3 (Charlie) Priority casualty. Concerns in order:

1. Working from centre mass to extremities, determine if the chest wound is an avulsion; large, medium, or small velocity wound and bandage accordingly.
2. We dont know how long the tourniquet was on, so pop that off.
3. Assess pain, often by asking the patient "how's the pain" - though in real life we'd ask on a scale of 1-10, 10 being the worst pain they've ever experienced - in arma it's easier to ask them if its noticeable.
- If the wound is to one of their arms, its likely this will lead to a lot of weapon-sway and weapon accuracy difficulties, so treating that pain is an appropriate measure.
4. Take vitals, I like to start with BP but pulse is an appropriate place to start too. For this example we find 101/79, pulse reads 80. - Both are fine. If they suffer further injuries they may require a transfusion once systolic pressure drops below 100, however.
5. If they find the pain difficult, these vitals are appropriate to administer a shot of morphine if they find it necessary - though its not required.

Note, if their vitals were lower, for example if their pulse was below 60, bradycardia, administering morphine would cause them to hear their heart rate. If you choose to administer morphine for the pain and they hear their heart rate, or you assume they will, follow with one shot of epinephrine as well to counteract any CNS, central nervous system, suppression associated with morphine and opioid agonists.

|| Tip: If you're treating the patient in tandem with other medics or CLS, announce what you're doing. Example: "bandaging left leg" or "getting vitals ... (and proceed to announce those vitals) ... BP 89/50", etc.

Conclusion to example: The patient can be released, notify them their wounds may reopen, to treat the arm with an elastic and the chest with a packing bandage. Remind them if they hear their heart-rate to find a medic.

Advanced Treatments

Often a casualty will sustain more significant injuries, or go untreated if they dont notice or dont treat previous injuries. As a result, wounded may present with more complex wounds requiring advanced treatments.

These may require:

Medication
Blood Transfusions
Personal Aid Kits
And surgery

Medication:

Meds administered to patients should adhere to the rule of 3 - no more. If you have to administer more than 3 morphine, or more than 3 epinephrine, the patient will more than likely go into shock or die. This said, dont be afraid to utilise these meds, especially with extremely wounded individuals - just be able to justify your decision based on the vitals you determine after regular reassessments.

There are several types of autoinjector medications available in ACE advanced medical:

Epinephrine (quantity 8 / medic) - A sympathomimetic that increases heart rate and blood pressure.
Morphine (quantity 10 / medic) - Provides analgesia (relief of pain) as an opioid agonist at the cost of CNS suppression.
Adenosine (not generally issued) - A coronary vasodilator that increases bloodflow, decreasing heart rate without analgesic effect.
Atropine (not generally issued) - An anticholinergic substance that decreases heart rate, without analgesic effect.

|| Note, DO NOT administer medication to a limb that is constricted by a tourniquet, it will have no effect until the tourniquet is removed and thus release massive quantities of morphine or epinephrine into the patient, often resulting in death. A hapless medic is death's helping hand.

Introvenous Transfusions & Fluid Resuscitation:

There are three fluids we administer via IV to increase blood volume, which when combined with astute epinephrine administration can increase blood pressure.

Saline (quantity 4 bags 500mL each / medic) - Lasts 15min before losing effect. Can be used in the field to manage minor blood loss. 1000mL bags can be found in the FH, but are less useful than other IV fluids.
Blood (In CCP/FH 250mL, 500mL & 1000mL) - Replenishes blood loss and should be used frequently.
Plasma (In FH 250mL, 500mL & 1000mL) - Replenishes blood loss and restores some clotting factor for coagulopathies like hemophilia.

Systolic Thresholds:

The human body has roughly 5-6 litres of blood, and what goes in may come gushing out elsewhere, so make sure all open wounds have been bandaged and are showing as blue on the patient treatment screen.

The medical menu may say "Lost a lot of blood" in the status field on the right - this isn't always true however, so it's best to use BP thresholds to determine the quantity of IV fluid that should be provided, as it's actually quite simple: Remember 120/80 (systolic/diastolic) is the objective.

>Below 120, above 100 - 500mL saline or blood.
>Below 100, above 80 - 1000mL saline or blood, preferably blood.
>Below 80, above 60 - 2000mL blood or plasma. Plasma especially if the patient has numerous wounds and has been hemorrhaging while bandages keep reopening.
>Below 50 - Open line 4 litres of blood and plasma, prefferably 2000mL blood, 2000mL plasma.

Be aware that sub 50 systolic pressure generally means the patient is unconscious.

Surgery & PAKs:

Once bleeding has stopped, medication has been properly administered, and all limbs which were wounded show blue on the medical menu, the use of a Surgical kit or PAK (Personal aid kit) are available.

All leadership carry a PAK, which can only be used on a stabalised patient in a CCP or field hospital. Once used, a PAK restores the patient to pristine health, without necessity of a blood transfusion, so it is often advised if you intend to use a PAK that the patient be stabalised and then administer the PAK without the blood transfusion, as it resets their medical status to no pain, no wounds, pulse 80, BP 120/80.

However, PAKs are finite, and once used they disappear. A surgical kit has unlimited uses, and can be used in a field hospital or CCP. The surgical kit still requires all wounds blue, however, it will not reset medical, only alleviate wounds. Pain and blood loss remain after a surgical kit is used and thus must be used in tandem with the administration of medication and IV transfusion.

Advanced Medical Example

This example is based on a casualty I treated recently during a MOUT operation in Helvantis.

Patient presents unconscious at the CCP with a large velocity wound to the chest, avulsion to the left arm with a tourniquet, small velocity wound to the right leg without tourniquet, and an avulsion to the head he has been bandaging throughout the mission with elastic. BP is 49/30, heart rate is 39. This is a Category 1 (Alpha) Urgent Casualty.

1. First stop the hemorrhaging chest wound with a quick-clot, if available, as its a large wound to the torso where bleeding will remain torrential.
2. Tourniquet the right leg prior to applying a packing bandage to the small velocity wound on the right leg.
3. Elastic bandage to the left arm where the avulsion is meagerly managed by the tourniquet. Removing and reapplying the tourniquet when the avulsion was bandaged to buy time.
4. The chest reopened, so I followed with another packing bandage to the large velocity wound in the chest.
5. Re-assessed patient's vitals finding a BP of 35/20 and a heart rate of 39.
6. Began an open line of 2 litres, 2000mL of blood to the left leg, because it is one of the only un-injured extremities I can start the transfusion in.
- Note if you begin a transfusion in a limb that has a tourniquet applied to it, the blood will not flow or will flow minimally, thus it is imperative this is applied to an open limb or the tourniquet is removed before transfusing.
7. Pushed one epinephrine and one morphine autoinjector into the left leg.

|| Moved on to another wounded individual during triage, returning to reassess vitals less than 20 seconds later.

8. Example patient showed BP of 50/30 and a heart rate of 40. Always reassess patients every 20-30 seconds, especially after administering medication and IV transfusion.
9. Pushed an additional litre, 1000mL of blood and 500mL saline (all I had) into the left leg followed by epinepherine to increase circulation and morphine to decrease shock and pain.
10. Reassessed over 60 seconds, BP rose to 80/50 and a heart rate of 60 - he woke up not long after.

Conclusion to example: The casualty was in dire straights when he arrived, and though there were two other unconcious patients I was tending to at the time, if he'd been one of five I'd have considered him a lost cause. He was the most wounded we had in the CCP at that moment with more critical casualties en route. Once awake, the mission ended, however if it had not I would have tranferred him to the field hospital for surgery, solicited the medical officer bring a surgical kit to the CCP, or beg his fireteam leader or my Squad leader for their PAK to complete treatment. In his condition any significant movement would have reopened his injuries, leading to further bloodloss, shock, unconsciousness and death.

Conclusion of Pre-hospital Trauma Life Support & TCCC

This should be just about everything. I attempted to stay away from the Revised Trauma Scoring and START pneumonics, though some detail really applied to the serious subjects, and boiled down to the key points of acting in TCCC as a medic with Coalition. If you have any questions please do not hesistate to contact me, Cpl. Koala on discord for further information.