SHTF Combat Casualty – Considerations & Realities

AAR # 2 – Sept 14/14 CRCD Training Weekend
September 18, 2013
AAR # 3 – Sept 14/14 CRCD Training Weekend
September 19, 2013
On my CRCD class, I don’t have time to do a full class on TC3 (Tactical Combat Casualty Care). However, what I do is give a few pointers as to how causalities will fit into the game in a real SHTF contact situation. I’m going to try and replicate some of those pointers here:
When I train people in patrol break contact drills, I explain that it is like practicing a fire emergency drill. The fire alarm goes off, we all head downstairs and rally in the parking lot. Simple. But in the reality of a fire, we may not all get out, it may be a smoke and  flame filled confusion, and we may take casualties. It’s the same for break contact drills.
So, we practice our choreographed drills and at the level of the CRCD class I don’t even throw in casualties. The worst case reality of a break contact drill, facing a well sited enemy ambush, is that you may get out crawling down a creek bed dragging your wounded buddy. Or you may not get out at all. But that is worst case. 
Break contact drills are ‘Oh Shit’ emergency drills and there are worst case scenarios. The other side of that is that with a well executed drill, even though you are doing the drill to ultimately get away, you may react and hit the enemy in such an effective way that you leave them reeling, wondering what happened as you “faded away into the woods.”
In the immortal words of Captain Jack Sparrow of ‘Pirates of the Caribbean’ fame: “We will fight them, to run away.”
The main point that I want to bring out today is firstly the effect of casualties on your drill, and secondly the effect that SHTF will have on your TC3 procedures. 
Firstly, the hardest thing you will do is going to probably be evacuating a casualty under enemy fire. Moving a casualty is very hard. Initially, you will be dragging the casualty by his gear every bound back that you make. You will move, dragging the casualty, covered by the other buddy pair. Then, you will stop, take a fire position, and fire to cover the withdrawal of the other buddy pair. As you get further away from the contact, creating a breathing space, you can consider reorganizing slightly so that, depending on the size of your team, there is an element moving the casualty and an element fire and moving back to cover that. For a four man team with one casualty, that will mean one person moving the casualty, whether by dragging or the Hawes carry, and the other two bounding back to cover that move. 
Once you rally up out of contact, you can reorganize, again your numbers will determine exactly how you do that (are you a team or a squad?), to create a litter carry party and a security party to cover the move out.
Secondly, let’s look at the reality of TC3 in an SHTF situation:
There are three phases to TC3:
1) Care under fire
2) Tactical Field Care
3) Evacuation
In the Care under Fire phase, the primary thing you must concentrate on is fighting the battle. If you are breaking contact that means do that. Don’t do anything that will cause more casualties, such as running out in the open to get that downed point man, unless you have first suppressed the enemy. 
Th only intervention you, or the casualty, can do in the Care under Fire phase is to apply a hasty tourniquet ‘high and tight’ on a wounded limb to stop imminent death from extremity bleeding. As a team you will be going through your individual RTR drills, reacting to the contact, and then flowing into the break contact drill as appropriate. If you have a man down, you will simply have to grab him and drag him back on each bound you make back as part of your fire and movement.

Even in the care under fire phase, don’t try and put a tourniquet on in an exposed position. Drag the guy into a semblance of cover, be practiced so you can whip it on and tighten it down quick either in the groin or armpit area, and then get on with firing and moving. If you kneel in the open to apply a tourniquet, you will be shot down.
If you are in some other contact situation where you are not actually moving and breaking contact, and you are engaged in a  firefight with a casualty exposed in the open, then don’t risk all to go to them. Concentrate on suppressing the enemy and winning the firefight. There are pretty much four things you can shout to them under TC3:
1) Can you return fire?
2) Can you apply self-aid? (i.e. hasty tourniquet high and tight)
3) Can you crawl to me?
4) Lay still! (so as not to draw more fire – don’t tell them to “play dead”, it’s not good psychologically!)
But, dependent on the situation you find yourself in SHTF, there are some other considerations. You probably don’t have back-up and there is no ‘dust-off’ medevac on the way. If the guy is obviously dead, grey matter on the ground or whatever, then look to the greater good of the team and fight out of there. SHTF will make you face some hard decisions. You may not be able to bring them all home. The other side of that is that wounds can be horrific and look a lot worse than they are. So long as the guy is breathing, even better screaming, then do your best to get him out of there, even though you may be repulsed and unsure how you could ever take care of such a nasty wound. 
The next phase to look at is the Tactical Field Care phase. This is where training can diverge from the SHTF reality. In training, once you have suppressed the enemy and got the casualty to cover, then you can go into Tactical Field Care, which means taking care of H-ABC (now MARCH, same thing) and then the full assessment before packaging up the casualty (thermal blanket to prevent hypothermia, even in hot weather) and monitoring them for evacuation. This is where a whole bunch of interventions are possible. However, in SHTF I can’t tell you who your enemy will be. Worst case, they are an aggressive force that will follow you up, potentially even a Regime style ‘enemies foreign or domestic’ hunter-killer force. If so, you will not be able to hang around in the rally point for longer than it takes to do a personnel check, tactical reloads, and maybe a quick intervention on the casualty. Other than that, if you hang around and they follow up into your hasty ambush established as part of the rally, you will be back in contact and will have to roll back into the break contact drills again, back to another rally point. Don’t hang about after breaking contact.
In that sort of situation, you will have to do what you can for the casualty as you move back, creating further distance as you E&E away from the contact point. But here we hit another dilemma. You need to have equipment with you, and personnel, to carry the casualty. If you are using a litter, one casualty will take a squad to move – four on the litter at any one time, struggling, and the others pulling security as you move. You could use other methods, such as the ruck-style carry straps allowing one person to carry the casualty, but all this is going to be really hard work and make you slow. 
Enter: more hard decisions: how badly wounded is the casualty? Do you have definitive care to get him back to? How hard are you being pursued? Can you take care of the pursuit with a hasty ambush, or are you in serious trouble? Can you move fast enough to get away while moving the casualty? Will the casualty survive the evacuation (which as non-medically trained personnel you may not even know)? If you leave the casualty, what will the enemy do to him? Maiming, torture, cannibals, interrogation? Is leaving the casualty a security risk to your teams operations and ultimate survival? Do you have a contingency plan for team members falling into enemy hands – can you move your FOB location faster than you expect him to break to interrogation?
No, I’m not advocating that you shoot your guy and leave him, or that he shoot himself. But this may be a time for a little volunteer heroics from the casualty, which always carries a risk of capture. It all just depends on the situation, and no doubt an SHTF or civil war/resistance type situation is going to throw up some really hard choices. Some of this ties in with comments that I have made before about dumping gear to get away, running off naked through the woods after having dumped all your gear to escape. The key here is to carry a load that you can move with, and shuffle-run out with if necessary, so you never have to dump all your weapons, ammo and gear even if you dump your patrol pack. If you are being closely pursued, whether you have a casualty or not, then you may face a choice of dumping everything and running, or you may turn and fight, hasty ambush, get close to the enemy negating indirect fire weapons, and maybe survive in the chaos, in the gaps. That is your choice and largely depends on what you are about i.e. what you see as your mission. 
There is a time to live, a time to fight, and a time to die. All that really matters is how much it’s going to hurt, right? If you are going to go out like a fighting bear, go out like a grizzly.
This leads us on to the last part, which is evacuation. The whole point, in a nutshell, of the TC3 protocols is basically to stabilize the casualty and keep them alive so that they can be evacuated back to definitive care, in military terms at the CASH (Combat Hospital). But in SHTF you will only have whatever medical care you have. Whether that is a medically trained person, or yourself having read up and taken some courses.
The interventions that you do under TC3 protocols rely on further definitive interventions back at the hospital to take care of the problem. You have to take that tourniquet off some time right? Are you going to clamp that artery? Do you have the equipment? You have to get a chest tube in to take care of the sucking chest wound and tension pneumothorax (collapsed lung), right? Can you get over your own feelings of revulsion at the gore and blood in order to be effective in helping your buddy or family member?

So ultimately, keeping the guy alive until you can get him out will then rely on being able to keep him further alive by definitive interventions. You may be back to an 1860’s level of medicine, giving him a bottle of whisky to drink while you do what you can. So, you need to be able to clean, debride and suture wounds. You need to consider antibiotics, because back in the day infection was the major killer of those who initially survived their wounds. Think about use of betadine/sugar poultices and similar, as used by vets on horses. 
So, ultimately what is my point? Like all military style doctrine, it has to be assessed and looked at from the perspective of an SHTF situation. TC3 is no different. It is really useful to train as a combat lifesaver or combat medic and to learn to do TC3. But make sure you have assessed the use of it in a non-military SHTF environment and consider the potential absence of definitive care as well as the need for people in your group to step into those gaps with useful skills.

Live Hard, Die Free.



  1. Anonymous says:

    Thanks for the photos Max the “boys” needed a reality check. Well. for starters; both of the men in the photos are KIAs without MEDIVAC. In SHTF(no doctors) you can let them bleed out, or drag them around till they die of gas gangrene. but without a trauma MD. and a S*** load of professional care they have no chance of recovery. BOTH of them are amputees(look closely at the first guy- he’s shot thru the Fib-Tib. with bitts of bone sticking out-that legs coming off ) Nether man will ever walk without prosthetics. IF THEY LIVE- and I wouldn’t give good odds on that with a good trauma doc. Guys if TSHTF and you don’t have an underground hospital, you and your people will die if hit badly. If you allow them to be “taken alive” for “care” by your enemy THEY WILL be made to TALK, telling everything they know about not only you but your family’s as well. Look if this starts there’s not going to be any red cross-no POW camps with funny Col. Clink. This will be dog-eat-dog AT BEST, and it could get way worse from there. If you are in an irregular unit without support, you ARE NOT gonna bless the guy who drags your A** through the bushes till you beg for death. If you need an airway, If you have a traumatic Amputation, If you get gut shot-head shot-lung shot , you are probably going to die without hospital care. If you can’t deal with that you are in the wrong outfit.—Ray

  2. JC Dodge says:

    Great reality check Max, concerning TC3 in SHTF. It could be a loved one, and hard decisions will have to be made. There’s alot to be said for having medical gear in your stores, that goes well above your training. You never know who you might run into post SHTF.

  3. Curtis says:

    The reality is, in a SHTF scenario, it may just be best in some situations to have one of your team members put a bullet in your head. That is something that should be talked about within everyone’s team/group/tribe.

  4. Anonymous says:

    I’m not saying life is easy, but don’t be too quick to give up. People have survived with less than perfect conditions. Check out this short article on the Civil War and amputees. The condition that some of these were performed in were very basic and unsanitary due to their lack of knowledge. JC Dodge makes a great point on having medical gear beyond your training. You can’t save everyone, but don’t call it quits too easily either.

  5. Georgia Jeff says:

    How bad will it get? This bad…Once a resistance unit sees their comrades in the conditions pictured above, they will revel in seeing regime fighters scream and howl in anguish. I remember in ‘Saving Private Ryan’ hearing the American troop telling the others to hold their fire and let the German burn. Remember in ‘We Were Soldiers Once’? The photog dragged the guys skin off his legs.

    IEDs. Incindiary IEDs.(These look like IED casualties.)

    And an injured man takes at least two out of the fight. A dead fighter needs no care.

    I agree with Ray. The only chance of survival for the two casualties above are prompt and competent medical care. Dragging them around in the dirt is torture prior to a slow septic death. Morphine. Maybe even a lethal dose.

    All of these dark realities should give a sane person pause to think. I prepare for this, but I pray to God it never comes to pass.

  6. Georgia Jeff, that incident from WE WERE SOLDIERS actually happened. (If you already knew that, my apologies.)

    There is no dishonor in doing what must be done. No sin either. Men in that condition cannot be saved without trauma care. The injury is too great. A quick prayer if there’s time. Put the barrel to his temple and pull the trigger.

    Remember Kipling: “If you should fall on Afghanistan’s plains, and the women come out to cut up what remains, roll to your rifle and blow out yer brains, and go to your God like a soldier.”

  7. Anonymous says:

    Christ, some of you guys are a little melodramatic.
    The two above casualties were rather common on battlefields in 1863. There were no super well qualified medical doctors back in those days, their qualifications revolved primarily around how to deal with these exact wounds. Many did die from the infections brought on by the amputations but many also lived. My point is that we are not racehorses who have to be put down simply from taking an injury. I got news for you. I am not going to fight with a team that leaves their casualties or kills their own wounded. You want me to have your 6 you better damn well have mine and at least get me back to the FOB to die later from infections. Thats a serious threat to motivation right there. I dont take that as what Max is saying here. Maybe he can clarify but I take it as a serious call to build that post incident and long term habilitating care. How many of you know Doctors and Nurses? How many know Vet’s who could possibly perform surgery if they needed to?
    How many could just ask doctors what kind of gear they would need to run a trauma facility at least to WW2 standards? Then you can begin to collect that gear locally for them.
    How many EMT’s do we know?
    Could we do the same thing for them? Build an “EMT in a box” with the gear needed to support the EMT in his efforts to perform CASVAC?
    I think about these things probably more than I should but I do.


  8. Anonymous says:

    Sort of related topic – arrowhead wounds causing more damage then realized.

  9. Curtis says:

    The upcoming festivities are going to be nothing like the our past Civil War. It just amazes me that people are still dreaming of revolution/civil war past. The uniforms are not going to be Blue vs. Red or Blue vs. Grey. There may or may not be a rear. There may or may not be a sanctuary. There may or may not be a field hospital…

    There will be considerations and some hard decisions concerning casualties. And those will be based on the environment one is in and the injuries. And depending on what is left of society, surviving a single/multiple amputation may be your death regardless.

    If I am out on patrol from resistance camp zulu out in the middle of the boondocks and ambushed, losing my legs, hauled back from the ambush back to resistance camp zulu, patched up… then what? What am I going to do? Where am I going to go? Get fitted with prosthetics and be you camp radioman, cook, mama-san maid now? Be discharged back into whatever is left of society?

    People are going to have to face up to the fact that there are going to have to be considerations in the environment that they are in… that’s all.

  10. What Max has presented, with SHTF scenarios and YOU as the insurgent is 100% correct thinking.
    The whole concept of TCCC is to give the field medic the ability to keep anyone with a survivable wound
    alive for 72 hours with the ultimate goal of arriving at tertiary medical care in that time. Survivable combat
    wounds have gone from 38% death rate during Vietnam to 1.5% for OIF/OEF because of TCCC.
    The question he is trying to get you to think about is this; TCCC can be taught to anyone, I have trained
    everyone from Marine mechanics to Navy cooks and this shit works. But what are you going to do once
    you have gone through MARCH and you are baby-sitting a 230 lb. man who can’t even take a piss without
    your help? The other folks who shot your team up will have evacuation and advanced medical care. What
    about you? Have you made a plan for this? When you are forced to defend your bug-out retreat it will be too
    late to go pull a book out of your library and start reading what to do.

  11. There’s no way of preparing psychologically for such injuries. I remember reading one of Selco’s SHTF’s articles, of his first experience of people getting shot & injured in the Balkan War. Just standing on a streetcorner waiting for a bus a man was shot & injured, & a woman nearby went into a state of shock trying to help him, and others ran for cover, but spent too long doing it & were cut down, & so on. He describes how sudden & totally beyond all previous experience this was. People just couldn’t cope, the blood and noise, the separated body parts, the screaming & chaos. I suppose this is how it would be in the early months, acclimating won’t happen fast, if at all.

    And in the Balkans they had been used to low-level violence, of threats of same, & in many cases people were living rough already. Imagine how much worse the sudden descent into SHTF conditions will be in the US, with its unprecednted creature comforts, services, & plentiful food. The existential shock will be profound. Adapting to all this will simply be beyond many people, beyond maybe most of us …

  12. Anonymous says:

    @anon 10:03
    I know, what a bunch of crybabies. I only get concerned when I’m holding my still beating heart in my hands after someone ripped it out and gave it to me right before stealing my favorite MRE. Or even worse when I’m looking at my body flopping around and realizing that my head has been separated from it.

    But yeah, depending on how bad things are you may not be able to be fitted with a nice peg leg let alone state of the art prosthetics. Some will survive no matter what but the majority of badly wounded probably won’t last long.

  13. Anonymous says:

    Really? Guys seriously. You think I am simply making light of the seriousness of casualties? or dreaming of the civil war? God help us sometimes the guys in the patriot community are just flat out too damn cranky to hear anything. I did not make light of the level of injuries possible or have visions of blue and gray. My point was that the level of casualty care that we have today is superior to the level of the civil war. Men routinely survived serious amputations and traumatic wounds with that very primative level of care. All of that was mentioned to counter the direction that comments were going which trended toward the very fatilistic and melodramatic. Reading these comments had me picturing men with scrathes on their legs urging their comrades to “go on without me I am a goner!”
    “Sorry Johnny I hate to do it but that shot in the arm is just to damn tough to deal with down the road, we got to put you down.”

    I am telling you to get the training to deal with the imediate casualty and build the network that you need to deal with the post incident care. We just have to worry about getting guys patched up and back to a realativly safe area to let those doctors deal with it. Please see the recent situations in Lybia and Syria and note the the media is filiming the wounded in local hospitals controlled by the rebels. We will have critical medical care, it may be of lower quality and many will still die but it will be there. If your plan does not include it then your are fucking it up already.


  14. […] post would be usefully read along with ‘SHTF Combat Casualty – Considerations & Realities‘. Remember that these TC3 protocols assume evacuation to definitive care (Combat Hospital), […]

  15. […] post would be usefully read along with ‘SHTF Combat Casualty – Considerations & Realities‘. Remember that these TC3 protocols assume evacuation to definitive care (Combat Hospital), so in […]