Comments on Casualty Evacuation & Treatment

First, I’ll say that this will be a brief post because I will be at the training site all week and have a training weekend coming up. I will be posting less frequently this week, if at all, but I will have access to the internet via cellphone and will respond to any interesting comments or questions as appropriate/possible.
The point of this post is to respond to some interesting comments on this post: Useful Patrol Training Video: there is a discussion in comments about the medical protocols shown in the linked TV show and how it relates to the availability of definitive care at a hospital.
This is very relevant and it is something that I discuss when teaching TC3 (Tactical Combat Casualty Care). (As an aside, it also shows the necessity, as I often remark, of breaking away from a dogmatic reliance on sources such as military doctrine/FM’s and training where it need amendment or does not apply).
This is not intended to be a post on TC3 protocols in detail. Although I skimmed watching the medical parts of the linked video, I did listen enough to hear discussion about the ‘Golden Hour’, which applies to the window of treatment desirable for best chance of recovery for a casualty. The Naval surgeon on the show, Rick Jolly, is legendary in the field from his actions in the Falklands War. He utilized  techniques such as leaving the gunshot/shrapnel wounds open for several days to reduce infection. Interestingly, in discussion with a British Military surgeon in Southern Iraq, I discovered that the British Army protocols were changed to a two hour window or ‘Golden 2 hours’ simply because of a mixture of long transit times across the desert even in medevac choppers, and also better skills and equipment utilized by medics for keeping people alive until they could reach the hospital. Interesting how the reality of transit times changed the understanding of the ‘golden hour’!
The three phases of TC3 can be summed up as:
1. Care under Fire
2. Tactical Field Care
3. Evacuation and definitive care at a hospital
This is where the commenters are right, and TC3 starts to lose its utility in an environment where we don’t have ‘dust-off’ to the Combat Hospital (CASH), or we don’t have a civilian ambulance to the nearest emergency room. This is what I am careful to explain in my classes: 
In an SHTF or Resistance environment, you won’t have those resources to evacuate your casualty to. You may have something, but it won’t be the CASH or the emergency room. Do you have a nurse in your group, a veterinarian, and EMT, a general practice doctor, an OBGYN for example, or did you just read up on wound treatment yourself and maybe take a couple of courses?
You have to appreciate and remember that all the things that a combat lifesaver or combat medic does at the point of wounding is designed to keep the casualty alive until they can be evacuated to definitive care. If there is no definitive care, then it is no good keeping the casualty alive in the first instance if they are to die later. It is, for example, fine to put a tourniquet on a wounded limb ‘high and tight’ in the care under fire phase, but unless you can ultimately downgrade and then remove it without the casualty dying them they will lose the limb. We could be talking about an 1860’s level of definitive care here with ‘sawbones’ doctors taking off limbs and casualties surviving or dying from blood loss and infection as a matter of chance.
In the video, the four man SAS patrol was behind enemy lines and on the run, and had to leave their wounded comrade. All they could do for the dead guy was to take his weapons and ammo. That is a far cry from ‘no man (or body) left behind’ U.S. Military doctrine that is achievable because the U.S. has the assets to be able to act like that. In an SHTF or Resistance environment there will be hard decisions to make. 
This does not mean give up on your casualties. It does not mean that TC3 protocols are worthless, because they are not. If you follow them, you will stand a better chance of keeping your casualties alive after wounding, and of successfully keeping them alive as you evacuate them by whatever means possible.
What you need to give serious thought to, and prepare for, is what to do after you have initially saved them. How will you evacuate them? What medical treatment can you give them? Do you have medically trained personnel to assist? If you don’t, then are you able to clean, debride and dress a wound? What about antibiotics – if we are back to ‘old school’ medicine then most of these casualties, if they survive the initial wounding, blood loss and treatment, would die from infection, particularly after an amputation. 
Food for thought.
Live Hard, Die Free.