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Care Under Fire (CUF)

Care Under Fire (CUF)

TCCC has 3 primary phases of care. Care Under Fire (CUF), Tactical Field Care (TFC) and Tactical Evacuation Care (TEC).

Over the next few weeks, we will be examining these phases of care individually to help you, the operator/emt/first responder have a better understanding of what your responsibilities are in each phase.

Care Under Fire

This phase, as its name suggests, is the most dangerous phase of attempting to render care. We all want to reach an injured teammate, friend, or patient as soon as we can to help, but we also don’t want to end up a victim ourselves and further complicate the situation. In this article, we will break down the traditional steps within CUF from a military perspective, but add additional implications for how EMT’s/ LEO’s and even civilians can benefit from these phases of care in their own situations of initial patient contact.

In a traditional military sense, this phase begins with the S is SMARCH-RV.

The steps are taken from the Advanced Tactical Paramedic Protocols Handbook put out by the Journal of Special Operations Medicine. The explanations and additional information are our own.


1) Return fire and take cover.

We’ve all heard that security is the best medicine, and taking another gun out of the fight to render aid potentially hurts everyone.   

For those both in and out of a war zone, security can also be replaced with situational awareness. Do we rush up to someone who appears unconscious, or do we look and see the live electrical wire near them that caused their unconsciousness?

Take the time to have a ‘tactical pause’ to assess the situation before rushing in and risk becoming another casaulty.

2) Direct or expect casualty to remain engaged as a combatant if appropriate.

Just because they are injured doesn’t make them helpless. They just had a traumatic experience. Help them stay focused on what they need to do in the moment to better their situation.

3) Direct casualty to move to cover and apply self-aid if available.

There is a natural tendency among those injured to immediately seek out the help of others to fix them. You, as a medical provider, need to remind them to help themselves if you are not immediately able to reach them. Proper training in quick and efficient tourniquet application, wound packaging/pressure, chest seal application and use of the material found in a traditional IFAK (Individual First Aid Kit) is essential here. If the first time applying any of these items to themselves is when they need them most, you have failed to properly train them. Period.

4) Try to keep the casualty from sustaining additional wounds

Patients who have received serious wounds will often not understand the severity of their wounds, or the adrenaline of the situation will allow them to keep going in such a way that adds to their injury. We’ve all seen that person with an obviously deformed limb insist that ‘they’re good’. Patients who have sustained concussive injuries through IED blasts or, blows to the head etc. will often put themselves in dangerous situations because they are suffering from confusion. Do what is necessary to keep the patient from complicating their own situation!

5) Casualties should be extricated from burning vehicles or buildings and moved to places of relative safety. Do what is necessary to stop the burning process.


You’ve reached the patient, but the patient is still in a dangerous situation. Do not treat the patient in a situation that isn’t bettering their outlook. Don’t treat a car accident victim on the side of the road if cars are still zooming by.  Don’t treat a gunshot victim in an area that is still receiving accurate fire….Get the idea?

Stop the burning process. Just because you have removed someone from a burning vehicle or put out a fire on an individual doesn’t mean you are done. To put it crudely, when you take a hamburger patty off the grill, does it immediately go back to room temperature and stop cooking? No. If someone has been burnt, take the steps necessary to try and cool that burn and stop the burning process immediately!

6) Stop life-threatening external hemorrhage if tactically feasible.

After Security comes Massive Hemorrhage in SMARCH-RV!


A) Direct casualty to control hemorrhage if tactically feasible.

In the order of care, stopping bleeding is the TOP PRIORITY!!!!

- Have tourniquet(s) in a spot where you can reach it with EITHER HAND!!!

- Practice placing your tourniquet one handed!

- We’ll repeat it again…if you are directing a teammate/friend to put on a tourniquet for the first time in a life-saving situation…you have both failed to train properly!!


B) Use a CoTCCC-recommended limb tourniquet for hemorrhage that is anatomically amenable to tourniquet use.

If you do not have a tourniquet, please get one and make sure you learn how to use it. The peace of mind you receive from simply having one available is tremendous.

Only 2 tourniquets currently recommended by Committee on TCCC. They are:

SOFTT-WGet one now!

CATGet one now!


C) Apply the limb tourniquet over the uniform clearly proximal to the bleeding site(s). If the site of the life-threatening bleed is not readily apparent, place the tourniquet “high and tight” (as proximal as possible) on the injured limb and move the casualty to cover. Ensure the slack is removed prior to cranking the windlass.

    * As long as you place the tourniquet CLEARLY PROXIMAL to the source of the bleed, you can place it lower than the elbow or knee.

    We understand that your job as a medic is not complete after the CUF phase. However, understanding this initial phase of care will allow us to build more advanced medicine that comes in the next step, which is Tactical Field Care.  Tactical Field Care comes only after these initial steps in CUF are complete.

    If you get nothing else out from this article, understand that situational awareness is key to treating a casualty. Take that tactical pause and assess the situation. Understand how you can handle the situation in the most effective manner in order to maximize the patient’s survival while not making yourself a casualty in the process. Have you properly prepared and trained your teammates/co-workers to be able to treat themselves if you can’t reach them immediately?

    Over 25,000 Americans unnecessarily bleed to death every year because people are either unwilling or unable to render the appropriate and timely treatment. Don’t be those people.

    Are you a civilian who still isn’t convinced about applying military style medicine to civilian applications? Maybe this Washington Post article that includes our friends from Next Generation Combat Medic can help convince you otherwise! 

    I Let A Man Die

    I Let A Man Die

    I let a man die.

    I was not yet a Green Beret Medic, nor was I a licensed medical professional, but I was directly responsible for a young man’s death. I was a junior in college, going for a run near Lake Shore Drive on a sunny afternoon during the summer months in Chicago. The steady pace of my run ceased immediately as I heard the squealing of tires and I involuntarily cringed as I heard vehicles violently collide nearby.

    The park, full of people on such a nice day, all turned with me as we strove to catch a glimpse of what had just occurred. A few hundred yards ahead of me, a small group of people began quickly moving towards what appeared to be the scene of the accident. Curious, and the accident being in the direction my run was already taking me, I picked up the pace until I reached the growing crowd. My heart sank as I saw that the majority of the crowd now stood over a young man who had been thrown off his motorcycle and laid in the grass nearly 50 feet from where is bike rested.  

    This young man, not yet unconscious but clearly in trouble and not understanding what had happened to him, laid half on his side, staring at his profusely bleeding arm, which had been nearly torn off in the accident. Both his legs lay at a funny angle, and his hair was matted in bright blood. Someone in the crowd said to no one in particular that they had called 9-1-1. As the group listened for the sounds of the sirens to let us know that help was on the way, we offered nothing in the way of assistance except silent hope and wordless prayers. A number of minutes later, the ambulance arrived and the EMT’s began working on him. I remember that he was still breathing at the time the EMT’s arrived, and continued my run confident that everything would be okay.

    The next day, I read that the accident I had witnessed the previous day resulted in the death of a motorcyclist. The man had died of his injuries. While it was a collective failure on the part of the entire group that had gathered around him to either be unwilling or unable to offer assistance, I felt personally responsible. The week prior, a friend who volunteered as a firefighter in Chicago had offered me a chance to take a first-responders course that Saturday, free of charge, at his firehouse. It being college, I had decided that partying and drinking were more important than getting up early, and had ridiculed him for even asking. 8 hours of learning how to stop bleeds, assist with breathing, and recognize the seriousness of injuries. I stood by almost exactly one week later and watched a man presumably bleed to death because I chose to drink rather than learn. I chose to spend Saturday hung over rather than learn exactly the type of emergency interventions that could have saved a man’s life. I didn’t just let a man die, my selfishness killed him.

    If you'd like to learn more about ways to save a life and gets the basics on trauma medicine, please visit the following links to help get you started.

    A few links to resources to get you started:




    There are plenty more basic and advanced classes given by the likes of:


    www.cagmain.com (former SF medic)


    www.d-dey.com (former SF medic)



    Top Dogs - MWDs, Police K9s and Working Dogs

    Top Dogs - MWDs, Police K9s and Working Dogs

    Military Working Dogs, or MWD's have been used as far back in recorded history as 600 B.C. War dogs, such as a now-extinct cousin of the Mastiff, were used to both kill and strike fear into the enemy. Though they have been used throughout history for various tasks, from beasts of burden to sentries, their modern counterparts came into play during the great world wars. In WW2, there were even dogs that were outfitted with their own parachutes, and participated in a British Parachuting Regiments jump on D-Day! Today we have over 2500 working dogs in the military, and tens of thousands more spread over police departments and government agencies. Their numbers will continue to grow as we continue to realize their importance.  

    We created @specialforcesmedics in order to highlight what SF life is all about, and over the past 3 years, we have strived to do just that. However, we also recognize that the experiences we have had doesn’t perfectly mirror what life is like for every SF guy, such is the dynamic of team life and worldwide deployments. For these reasons, we will occasionally highlight the contribution of different elements of team life in order to provide a better window into the lives of SF guys and our deployments, as well as what motivates Ready Warrior LLC to do what we do.

    It was our honor to work with fine dog handlers and their MWD’s during our time in the military. The courage they showed, the impact they made and the confidence they gave us day in and day out cannot be overemphasized. Sadly, we also saw the impact that war can have on the K9’s, as one of our dogs was sent home for PTSD (sadly, they get it too) and others injured or killed in the line of duty. Some of our bomb sniffing dogs were as friendly and gentle as could be, while others were little fur missiles who I swear could survive off their hate for…..let’s just say non-team guys! 

    This week, we will be featuring some K9’s that we or our friends have worked with during deployments to highlight their contribution and accomplishments. We also know that hard working K9’s are part of many military units, police forces and in the community, and we want to show our appreciation for all they, their handlers and trainers bring to the fight.  

    As a way to acknowledge these hard working teams, moving forward we will be selecting one K9 account/handler per month to receive our K9 Quick Reference Guide for free! What the heck are we talking about?

    Soon after starting Ready Warrior LLC and producing our medic guides, we started getting messages from K9 handlers in the military and law enforcement agencies asking if we had a K9 quick reference guide in the works. We did not. We were never dog handlers and never delved deep into K9 medicine, and thought these factors precluded us from being able to offer this as a guide. However, these requests became so frequent that it became evident that there was a true need for one to be written. It became our new obsession to learn as much as we could about K9 medicine. We talked with dog handlers, spoke with veterinarians, and most importantly, partnered with K911 Tactical to make sure we got it right the entire way. The response has been tremendous, and we sold out of our first printing in record time for guides.

    We want to get these guides into the hands of every handler out there, because we truly believe in them and the impact they can have on saving a dog’s life.

    So standby for future IG posts about how to nominate your favorite working dog and their handler for the chance to win a free K9 Quick Reference Guide! If you have any stories or photos of a K9 you worked with, drop us a line via DM on IG or here on the site.