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! 

    Ready Warrior
    Tagged: Care Under Fire