SHTF Combat Casualty – Considerations & Realities

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:
(For the full detail on TC3 itself, I did a post some time ago 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.