SOCM
Task Force Jackal
Special Operations Combat Medic
1 - Introduction
This document serves as the Training and Reference Manual for the Special Operations Combat Medic (SOCM) Course.
The course is aimed at personnel with no previous experience in the usage of ACE, KAT or ACM Medical or their respective subtypes.
The intent of this course is to build up each participants skill from a basic introduction to ACM Medical to a skillful application of predetermined treatments and interventions as dictated by the Medical Oversight Committee of TFJ in a timely and adequate manner.
2 - Terminology
2.1 - Introduction to Terminology
Being the introductory course to a professionalised medical setting, basics of medical terminology are an obligate part of Training the knowledge of which may be required or even tested at any time.
2.2 - Prefixes, Suffixes, Abbreviations and Useful Terminology
Medical Terminology is usually constructed by connecting a prefix (, root word) and suffix.
Below, you can find a table with relevant terminology utilised in this document and regular practice.
Uncommon terms are highlighted with the “ * ” Symbol to express their presence for the sake of completion and rare usage in applied medical settings.
PREFIX
TRANSLATION
SUFFIX
Airway / Breathing / Circulation / Bleeding
Airway / Breathing
pulmo-
Lungs
-thorax
Condition of the chest
pneumo-
Air
-pnea
Relating to breathing
angio-
(Blood) Vessel
-capnia
Relating to CO2 Levels
cardio-
Heart
-tension
Pressure
hemo-
Blood
-oxia
Oxygen Status in tissue
cyano-
Blue Color
-ventilation
Movement of Air in and out of Lungs
Speed / Degrees / Quantities
Circulation / Bleeding
bi-
two / both sided
-perfusion
Blood flowing to tissue
uni-
one / on one side
-cardia
Relating to heart rate
poly-
many
-rrhage / ia
Excessive Bleeding
SpO2
Blood Oxygen Saturation
2.3 - Triage Terminology
During Mass Casualty Incidents (MCI / MASCAS / MASCAL), proper unified terminology between all personnel on scene is imperative to keep communication functional in these stressful and critical situations.
To unify Casualty Classification Terminology, four Casualty Tiers are utilised. Casualties are classed according to the following graphic.
Tier
Description
T1
MARCH has been completed.
Casualty is currently in critical condition.
T2
MARCH has been completed.
Casualty is not in critical condition but requires further monitoring.
T3
Casualty has minimal injuries present.
OR
Casualty is only in need of secondary care.
T4
Casualty is deceased or expectant.
This terminology is universal between all members of TFJ.
3 - Introduction to Tactical Combat Casualty Care (TCCC)
Tactical Combat Casualty Care (TCCC) described the emergency care specifically relating to combat casualties and primarily focusing on early interventions in the field and generally separated from Tactical Evacuation Care (TACEVAC). The following passages introduce Tactical Combat Casualty Care in its individual aspects.
3.1 - Phases of TCCC
TCCC is generally separated into three (four) distinct phases. Treatment during these phases is defined by external factors such as enemy and friendly presence, composition and situation.
The phases are defined as follows:
3.1.1 - Phase 1: Care under Fire (CUF)
Care under Fire describes the first phase of TCCC. A casualty has been sustained and contact with hostile forces is either imminent, active or has just passed and the situation has not been secured.
The focus in this phase is establishing security either through fire superiority, retreat, reinforcing with other (infantry or support) units or any other means of securing the personnel rendering aid and the casualty during treatment without impairing combat capability.
Treatments in this phase are limited to immediately life-saving treatments such as Tourniquet Placement and generally to be performed by the casualty if they are conscious. Medics or Team Members may instruct the Casualty verbally as necessary.
If the casualty is unconscious, treatments performed by other members of the team should be critically evaluated as they bind personnel resources in critical situations where fire superiority is the preferred course of action.
3.1.2 - Phase 2: Tactical Field Care (TFC)
Tactical Field Care describes the second phase of TCCC. The situation has been secured and the casualty is being treated by (non-)medical personnel. Security has to be maintained at all times regardless of the amount of casualties.
The focus in this phase is maintaining scene security and providing aid to the casualties in need.
A CCP may be established if possible and necessary.
To assess and treat casualties accordingly, standardised Assessment and Treatment Algorithms and Triage Categories are utilised. The following steps should be completed for each casualty:
Casualties should be fully assessed according to the MARCH approach during this phase.
Casualties should be assigned one of the four triage tiers in accordance with the mSTART algorithm.
Casualties should be treated according to Task Force SOP and their casualty tier.
3.1.3 - Phase 3: Prolonged Field Care (PFC)
Prolonged Field Care describes the third phase of TCCC. A casualty has been treated in accordance with TFJ medical SOP and has been retriaged. Security and the ability to move casualties quickly has to be maintained at all times.
The focus in this phase is maintaining security and regularly (roughly every 10 to 15 minutes) checking on the casualties to track any deterioration in casualty status early on. Interventions to maintain casualty stability should be performed, if possible. A CCP should be established if possible.
To assess and treat casualties accordingly, standardised Assessment and Treatment Algorithms and Triage Categories are utilised. The following steps should be completed for each casualty:
Casualties should be assessed according to the MARCH approach with an emphasis on previously or currently present pathologies
Casualties should be retriaged based on deterioration in casualty status.
Casualties should be treated according to Task Force SOP, any uncertainties may warrant contacting a Callback Medic.
This phase described the timeframe after initial stabilisation and before casualty evacuation.
3.1.4 - Phase 4: Tactical Evacuation Care (TACEVAC)
Tactical Evacuation Care describes the fourth and final phase of TCCC. A casualty has been treated and handed over to a MEDEVAC / CASEVAC Team to be transported to a field hospital.
The focus in this phase is maintaining casualty stability. Interventions that are deemed necessary may be performed either before or during the transport, with indications set by the Evacuation / Flight Medic.
This phase of casualty care is generally delegated to Pararescue personnel. If other personnel find themselves in the role of an Evacuation Medic, they are encouraged to follow SOPs provided and contact a Callback Medic if uncertainties arise.
4 - Primary Assessment: MARCH Assessment and Interventions
The MARCH Assessment is the standardised casualty assessment algorithm in TCCC. It is equivalent to the (x/c)ABCDE Assessment in civilian settings.
The general prioritisation follows a “Treat First what Kills First” mentality.
A MARCH Assessment should always be done in full on any casualty during the TFC Phase of TCCC.
Immediately lifesaving primary interventions should be performed whilst conducting the MARCH Assessment to minimise time to treatment for critical casualties.
Secondary interventions should be performed after conducting MARCH to maintain the quick flow of assessment and triage.
Note that the MARCH Assessment is a quick primary assessment that should be conducted rapidly without the usage of electronic aids such as an AED. Pulse Oximetry may be considered but is not necessary for initial assessment.
In the following paragraphs, MARCH is broken down into its individual components and diagnostic strategies are discussed.
4.1 - M: Massive Hemorrhage
Massive Hemorrhage is defined as immediately life threatening bleeding. Massive Hemorrhage can present either externally or internally, with the former being quick to diagnose and treat whilst the latter requires some diagnostic skills, contextualisation and invasive measures to control.
To assess for Massive Hemorrhage a medic should:
Check limbs, torso and head for any massive, bleeding injuries (Large Cuts, Large Avulsions, Large Velocity Wounds)
Check Torse for any Velocity Wounds as a possible cause of internal bleeding
Note that not all external bleeding is critical in nature. Small, isolated wounds may be ignored in this part of the MARCH Assessment. Instead, providers should advance to the “Airway” part of the assessment.
Any presence of Massive Hemorrhage requires immediate and primary intervention to prevent casualty degradation. The following measures are adequate to treat life threatening external bleeding:
Bleeding on Limbs:
Combat Application Tourniquet (CAT) Placement on the affected limb
Bleeding on Head and Torso:
Application of Emergency Trauma Dressings (ETD, large scale dressing covering many wounds)
Application of Packing Bandages (smaller bandages covering fewer wounds)
After the intervention, its effectiveness in compensating any critical active bleeding should be reassessed.
4.2 - A: Airways
During the “Airways” phase of the assessment, casualties are assessed for patency and risks to the airway. An Airway may be acutely compromised or potentially endangered (especially in unconscious casualties), warranting different primary interventions depending on casualty presentation. Airway status and Tracheal Deviation may aid in diagnosing underlying pathologies and should be noted.
To assess the Airway a medic should:
Check the airway for partial or severe collapse, obstructions, inflammations and spasms
Check for Tracheal Deviation, indicating a possible TPTx/THTx
Note that any form of airway compromise is immediately life threatening and should be compensated appropriately with the available materials on hand.
Any presence of Airway compromise requires immediate and primary intervention to prevent casualty degradation. The following measures are adequate to treat airway compromise in the described situations:
Airway Obstruction: (Note that bleeding on the head may also cause airway obstruction)
Head Turning (clears slight obstructions)
Placing a Casualty in the Recovery Position (clears slight obstructions and prevents further obstruction
Usage of the Emergency Disposable Suction Bag (EDSB)
Usage of the ACCUVAC Suction Device
Airway Collapse: (Note that an escalative approach often serves casualties best)
Head-Tilt Chin-Lift (active action, keeps the airway open with slight to moderate collapse)
Placing a Casualty in Recovery Position (keeps the airway open with slight to moderate collapse)
Nasopharyngeal Airway (NPA) Placement (Manages slight to moderate collapse, may be used alongside Head-Tilt Chin-Lift to manage severe collapse)
I-Gel (Supraglottic Airway/SGA) Placement (Manages any collapse and prevents further obstruction of the airway)
Emergency Cricothyroidotomy (Surgical Airway, manages any collapse and prevents further obstruction. Keeps casualty permanently unconscious)
Severe Airway Inflammation: (Note that this occurs exclusively in CBRN Casualties)
Emergency Cricothyroidotomy (Surgical Airway, manages any collapse and inflammation, prevents further obstruction. Keeps casualty permanently unconscious)
Airway Spasms: (Note that this occurs exclusively with Sarin Exposure)
Emergency Cricothyroidotomy (Surgical Airway, manages any collapse, inflammation and spasms, prevents further obstruction. Keeps casualty permanently unconscious)
After any intervention, adequate management and patency of the airway should be reassessed. If definitive Airway Management (I-Gel, Cric) has not been performed and a casualty remains unconscious, their airway patency should be regularly reassessed and placement in the recovery position is recommended to prevent future obstructions.
4.3 - R: Respiration
During the “Respiration” phase of the assessment, casualties are assessed for respiratory pathologies. Note that unmanaged airway compromise may also cause respiratory compromise.
To assess Respiration a medic should:
Check for Cyanosis
Assess for Apnea/Dyspnea/Eupnea
Check for thoracic excursion, deviation and velocity injuries indicating a possible PTx/HTx
Auscultate the casualty to assess for diminished/absent breath sounds indicating a possible PTx/HTx
Check for thoracic bruising, indicating a possible HTx
Note that Apnea may be the result of airway compromise, as well as underlying respiratory or circulatory pathologies. If Apnea is present and airway compromise is not likely, advance to “Circulation” after performing primary respiratory interventions.
Any presence of respiratory pathologies require immediate and primary intervention or assessment to determine other causes, as to prevent casualty degradation. The following measures are adequate to treat respiratory pathologies in the described situations:
Cyanosis: (This step approach is strongly recommended)
Reassessing Airway Management if definitive Airway has not been placed
Continue in further assessment and compensate possible underlying pathologies
(If present without Cardiac Arrest) Ventilate with Oxygen
Apnea/Dyspnea:
Reassessing Airway Management if definitive Airway has not been placed
Continue in further assessment and compensate possible underlying pathologies
(If present without Cardiac Arrest) Ventilate with Oxygen
Inadequate Excursion/Thoracic Deviation or Auscultation indicating pathology:
Place a Chest Seal if possible (Note that a Chest Seal must always be placed if the option is shown as an open chest wound is present)
(If persisting after Chest Seal Placement) Perform Needle Chest Decompression (NCD) once
(If persisting after NCD or presenting with bruising) Contact Callback Medic to get clearance to perform an emergency thoracostomy, place a chest tube and drain once.
(If persisting after Chest Tube Placement) Check if Chest Tube is unsealed and reseal. iIf necessary, remove chest tube and stitch incision.
After any intervention, adequate management of respiratory pathologies should be reassessed.
4.4 - C: Circulation
During the “Circulation” phase of the assessment, casualties are assessed for circulatory pathologies that may also be the underlying cause of certain respiratory pathologies. Note that severely inadequate circulation and perfusion are immediately critical and may lead to a casualty falling into cardiac arrest.
To assess Circulation a medic should:
Check the casualties radial pulse for rate and strength (Tachycardia + Weak Pulse indicate shock)
(If lacking radial pulse) Check the casualties carotid pulse for rate and strength
Check a casualties capillary refill
Check for any bleeding external injuries
Check for any bruising indicating internal bleeding
Check for amount of blood loss
Note that the absence of a pulse means the casualty is in cardiac arrest. Traumatic Cardiac Arrest is discussed in subsequent chapters. It is of importance that CPR is not a primary intervention in the professionalised TCCC Provider Setting as it binds critical resources especially in incidents with multiple casualties. Critical Casualties with a pulse present take precedence over casualties in cardiac arrest until sufficient resources are present on scene.
Many circulatory pathologies require immediate and primary interventions to prevent casualty degradation. The following measures are adequate to treat circulatory pathologies in the described situations:
Absence of radial and carotid pulse:
Check if all relevant issues from M, A and R have been compensated
(If still absent) Check if resources are sufficient to start working traumatic arrest
(If not enough resources present) Continue to next casualty
(If enough resources present) Begin Traumatic Cardiac Arrest spiral
Weak radial / Lack or radial with weak carotid pulse / Inadequate Capillary Refill:
Check if all relevant issues from M, A and R have been compensated
(if still weak) Place IV / IO in Patient and administer 500ml of Saline
(if still weak) Administer further Saline up to a sum of 1000ml
(if still weak) Contact Callback Medic and consider Fresh Whole Blood Transfusion
Minor Bleeding present:
Address any minor bleeding with Packing Bandages
Bruising indicating external bleeding / Other signs of internal bleeding:
Place IV / IO in Patient and administer 1g of TXA IV
(reassess after 2 Minutes) If patient still actively bleeding (i.e. intrathoracic bleed) administer 1g of TXA
High Blood Loss with corresponding vital signs:
Place IV / IO in Patient and administer 500ml of Saline
(If issues persist) Administer further Saline up to a sum of 1000ml
Contact Callback Medic
After any intervention, adequate management of circulatory pathologies should be reassessed.
4.5 - H: Hypothermia / Head Injury
Hypothermia and Head Injury are as of now not modeled in ACM.
5 - Secondary Assessment: PWS
The secondary assessment PWS is performed after all casualties on scene have been stabilized and the scene has been secured. A secondary assessment is categorized as supportive and optional treatments to enhance casualty comfort or ability post injury.
Note that secondary interventions should only be conducted if resources on scene are sufficient and expendable.
The Secondary Assessment is structured as follows:
5.1 - P: Pain
Pain can have a significant effect on a casualties combat effectiveness post injury. It should be managed adequately if safely possible to do so.
Pain management should be performed in an escalative manner as outlined below.
Pain management should be viewed critically in vitally unstable patients.
Pain should be assessed and treated according to severity:
Mild Pain
Painkillers p.o
Pentrox inh.
Moderate Pain:
Painkillers p.o. + Penthrox inh.
Repeat once
Ketamine i.m. according to SOP
Severe Pain:
Penthrox inh.
Ketamine i.m. according to SOP
Contact Callback Medic
Note that any adverse reaction to Analgetics should be compensated immediately if possible.
5.2 - W: Wounds
Wounds that have been bandaged may require stitching as definitive treatment before releasing a casualty to the battlefield. Stitching may only be performed if safely possible to do so.
Stitching should be performed using consumable sutures if available in sufficient amounts
Bruises may be wrapped with Elastic Wraps to reduce inflicted pain.
5.3 - S: Splinting
Fractures require management prior to releasing casualties in order to guarantee adequate movement.
Fractures should be diagnosed as to their severity and treated accordingly.
Splints should be wrapped after application to prevent dislocation of the sprint.
Fractures should be treated as follows:
Mild / Severe Fractures:
Administer Lidocaine i.m. and wait at least 1 Minute
Perform fracture realignment
Apply and wrap SamSplint
Complex:
Establish Casualty Evacuation