This stage of special operations forces (SOF) combat casualty care denotes the care rendered by the special operations warfighter, combat lifesaver, or special operations medic at the point of injury (POI) while they remain under effective hostile fire. The risk of additional casualties (CAX) at any moment is extremely high for both the CAX and medical personnel; optimally, controlling the tactical situation is the key to saving the lives of the CAX.
The major considerations during this stage of care include:
• The suppression of hostile fire: The best management of CAX may entail the special operations medic moving with the fire team and providing effective, suppressive return fire. Ultimately, the tactical situation must dictate when and how much care the special operations medic can provide. Finally, when a casualty evacuation (CASEVAC) is requested, the tactical situation may not safely allow the air asset to respond. Remember in the care under fire phase, the treatment of CAX involve a combination of good medicine and good tactics.
• Moving the casualty to a safe position: When under effective enemy fire, the special operations medic (whether mounted or dismounted) cannot afford to rush blindly into the kill zone/danger area to provide interventions of questionable value to rescue a fallen comrade. Medical personnel are limited, and if injured, no other medical personnel will be available until the time of evacuation during the CASEVAC phase. Control of hemorrhage is vitally important as trauma involving major vasculature may rapidly result in hypovolemic (hemorrhagic) shock; non-life-threatening hemorrhage should be ignored at this time. Again, extremity hemorrhage is the leading cause of preventable death on the battlefield. Use of temporary tourniquets, such as the Combat Application Tourniquet, SOF Tactical Tourniquet, or improvised devices to control bleeding is essential in these injuries. If the CAX need to be moved, a tourniquet is the most reasonable initial technique to control major hemorrhaging and may allow CAX to continue the fight. Ischemic damage to the extremity is rare if the tourniquet is applied and left in place for less than one hour; in fact, tourniquets have been applied for 4-6 hours without deleterious effects. Israel Defense Forces reported over 90 cases of tourniquet application and found complications only after 150 minutes, none of which resulted in the loss of the injured limb. Again, management of non-life-threatening hemorrhage while under effective hostile fire should not be attempted and should be deferred until the tactical field care phase. Control of hemorrhage in non-extremity wounds may best be accomplished by the tried-and-true method of direct pressure using an Emergency Trauma Dressing or a combination of Kerlix packing and Ace bandages. If the hemorrhage site is accessible, hemostatic agents such as the HemCon, QuickClot, or Celox bandages, in conjunction with direct pressure, are more effective at achieving external hemostasis. Severe hemorrhage may also be the result of trauma to the neck, axillary, or groin area. Trauma of this nature is not amenable to the use oftourniquets; however, direct pressure and the use of hemostatic agents may be effective in bringing this type of hemorrhage under control. Note: As CAX may exsanguinate before medical help can arrive at the POI, guidelines that are more liberal have been established for the use of a tourniquet to control severe external hemorrhage from an extremity. As the presence of hypovolemic (hemorrhagic) shock is a grave prognostic sign, every special operations war fighter should carry a tourniquet and be thoroughly familiar with its application. Potential hazards of time and exposure to enemy fire do not warrant the application of a cervical collar for stabilization of the cervical spine prior to moving CAX to cover, particularly if they have sustained only penetrating trauma. Other neck injuries such as those resulting from a fall from 15 feet or more, fast-roping injuries, parachuting, or motor vehicle accidents may require cervical spine stabilization unless the danger of hostile fire constitutes a greater threat. In this case, cervical spine stabilization and long spine board immobilization will be a secondary consideration to moving CAX to cover.
In cases of blunt trauma, the risk of spinal cord injury from neck movement must be weighed against the risk of continued exposure to effective enemy fire. Studies have determined that only 1.4% of CAX with penetrating trauma might have benefited from cervical spine stabilization. Special operations medics should carry an adjustable rigid cervical collar in their medical aid bag. If rigid cervical collars are not available, a SAM Splint or a rolled blanket may be used as a field expedient collar. A long spine board is generally not available; however, there are many materials available in urban environments (door, bed frame, etc.) that may be used to achieve rudimentary spinal immobilization. Determine the potential risks associated with moving forward to a casualty’s position:
• Did the casualty result from a detonated mine or booby trap?
• Did the casualty result from an improvised explosive device (IED) or vehicle-borne IED? IEDs have been used to draw U.S. Soldiers into a coordinated, follow-on ambush or have subsequently triggered pre-placed, secondary explosives to kill medical responders and bystanders.
• Consider available assets; will the continued application of firepower outweigh any attempt to recover/transport the casualty at this time? Once you determine that moving CAX is warranted, standard litters are usually not available for moving CAX in the care under fire phase. Consider using alternative methods for evacuating them (short versus long distances):
• Short distances: Dragging CAX out of the field of fire by web gear, uniform, or even a length of rope attached to a snap link. º Manual carries (one/two-person drag, poncho drag, firefighter’s carry, etc.).
• Long distances: Commercial litters such as the SKED stretcher, Talon IIC, or Foxtrot may be available, especially if the unit is mounted. Improvised litters, such as discarded doors, bed frames, or other material may also be utilized. If these items are not readily available, and the risk of hostile fire injury to CAX requires immediate retrieval, CAX may be grasped by the shoulders of their uniforms, their heads stabilized by the forearms, and dragged along the ground to cover.
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