RFCT FY 19 EIB Medical Lanes

M7: Apply an Occlusive Dressing and Perform Needle Chest Decompression

1. Apply occlusive dressing. a. Expose the injuries. b. Apply an occlusive dressing to the entry wound. 1. Upon full expiration, cover the wound with large, occlusive material dressing, covering the first wound encountered. 2. Ensure the material extends 2 inches beyond the edge of the wound. 3. Tape all four sides of the dressing (If a non-adhesive dressing). c. Log roll the casualty on unaffected side and examine the back for an exit wound. d. Apply an occlusive dressing to the exit wound using the same standards as Step b. 2. Verify the presence of tension pneumothorax by checking for at least three of the indications below; verbalize as needed. a. Question the casualty about difficulty in breathing, pain on the affected side, or coughing up blood, and observe for signs of progressive respiratory distress. Grader will state, "Casualty is gasping for air and has pain on the wound side". b. Observe the casualty's bare chest for respiratory rate depth and abdomen for progressive distension. Grader will state, "Casualty has poor respiratory rate and depth, and the abdomen is mildly distended". c. Look for mediastinal shift manifested as a tracheal deviation and/or jugular distension. Grader will state, "Casualty does not have tracheal deviation, but has mild jugular distension". d. Look at and feel the patient's chest for signs of air in the chest wall (subcutaneous emphysema). Grader will state, "You feel a crackling sensation on the casualty's chest". e. Check for unilateral distension and chest expansion (excursion). 1. Place one hand on the affected side. 2. Place the other hand on the unaffected side. 3. Observe the height of each hand as the chest rises and falls. 4. Determine if the height of the hand on the affected side is greater during expiration than the height of the hand on the unaffected side. Grader will state, "The hand on the unaffected side is higher than the other". f. Look for bluish skin (cyanosis). Grader will state, "You observe mild cyanosis". g. Look for signs and symptoms of shock. Grader will state, "You observe two signs of shock-(Grader choice)". 3. Locate the insertion site. Locate the second intercostal space (between the second and third ribs) at the midclavicular line (approximately in line with the nipple) on the affected side of the patient's chest. 4. Thoroughly cleanse a 3 to 4 inch area around the insertion site. Begin in the center and work outward using a circular motion. 5. Apply a commercial needle decompression kit according to manufacturer's instructions or improvise by inserting a large bore (10 to 14 gauge) needle with attached catheter (steps below). a. Place the needle tip, bevel up, on the insertion site (2nd intercostal space, midclavicular line). b. Lower the proximal end of the needle to permit the tip to enter the skin just above the third rib margin. c. Firmly insert the needle into the skin over the third rib, until the pleura has been penetrated, as evidenced by feeling a "pop" as the needle enters the pleural space. d. Remove the needle and discard per unit SOP. 6. Decompress the affected side by aspirating as much air as is necessary to relieve the patient's acute symptoms. 7. Apply a commercial one-way flutter valve according to instructions or improvise (one method below). a. Cut a finger casing from a sterile glove. b. Cut off the fingertip. c. Tie or tape the finger casing to the needle hub. d. Check the operation of the improvised flutter valve. 1. Ensure that air passes through the needle-valve assembly and improvised flutter valve on expiration. 2. Ensure that the flutter valve collapses against itself on inspiration. e. Secure the catheter to the chest. 8. Measure pulse and O2 SAT. Candidate can perform this step on themselves or another soldier since the casualty must be a mannequin, or Grader may prep the device screen with degraded vitals. a. Wipe the index, middle, or ring finger tip with alcohol to ensure it is clean and dry. b. Apply the sensor. c. Document the readings on the TCCC Card. 9. Record all treatments on the TCCC Card. a. Front of card. 1. Evacuation (EVAC) - Mark an "X" on the casualty's evacuation priority/precedence (Urgent; Priority; or Routine). 2. Date - Write date of injury in DD-MMM-YY format. For example, "29-JUN-13". 3. Time - Write 24 hour time of injury, indicating whether local (L) or Zulu (Z) time, such as "1300Z". 4. Mechanism of Injury - Mark an "X" on the mechanism or cause of injury (artillery, blunt, burn, fall, grenade, gunshot wound (GSW), improvised explosive device (IED), landmine, motor vehicle crash/collision (MVC), rocket propelled grenade (RPG), other (specify)). Mark all that apply. 5. Injury - Mark an "X" at the site of the injury (ies) on the body picture. For burn injuries, circle the burn percentage(s) on the figure. If multiple mechanisms of injury and multiple injuries, draw a line between the mechanism of injury and the anatomical site of the injury. 6. Time - Write time of vital signs taken. 7. Pulse (rate & location) - Write casualty's pulse rate. 8. O2 Sat - Write casualty's O2 SAT. 9. AVPU - Write casualty's level of consciousness (AVPU: Alert, responds to Verbal stimulus, responds to Pain stimulus, Unresponsive). b. Back of card. 1. Evacuation (EVAC) - Mark an "X" on the casualty's evacuation priority/precedence (Urgent; Priority; or Routine). 2. C - Mark an "X" for all Circulation hemorrhage control interventions. For tourniquets (TQ), mark category (Extremity, Junctional and/or Truncal) and write name of TQ(s) used. For dressings, mark category (Hemostatic, Pressure, and/or Other) and write type of dressing(s) used. 3. B - Mark an "X" for all Breathing interventions oxygen (O2), needle decompression (Needle-D), Chest-Tube, (Chest-Seal) and write type of device(s) used. 4. First Responder Name - Print the first responder's name (Last, First). 5. First Responder Last 4 - Write last four numbers of first responder's Social Security number.

M3: Perform First Aid to Restore Breathing and/or Pulse

1. Approach the casualty and check for responsiveness. Grader will state, "Casualty is unresponsive". a. Direct a specific bystander to call for medical personnel. b. Direct another specific bystander to retrieve an Automated External Defibrillator (AED). 2. Roll the casualty onto his/her back. a. Kneel beside the casualty. b. Raise the near arm and straighten it out above the head. c. Adjust the legs so they are together and straight or nearly straight. d. Place one hand on the back of the casualty's head and neck. e. Grasp the casualty under the arm with the free hand. f. Pull steadily and evenly toward yourself, keeping the head and neck in line with the torso. g. Roll the casualty as a single unit. h. Place the casualty's arms at his/her sides. Grader will state, "Casualty does not appear to be breathing". 3. Open the airway using the head-tilt/chin-lift method. a. Expose casualty's bare chest. b. Kneel at the level of the casualty's shoulders. c. Place one hand on casualty's forehead and apply firm, backward pressure with palm to tilt head back. d. Place fingertips of other hand under bony part of lower jaw and lift, bringing chin forward. Do not use thumb to lift. Do not completely close casualty's mouth. Do not press deeply into soft tissue under chin. 4. Check for breathing. a. While maintaining the open airway position, place an ear over the casualty's mouth and nose, looking toward the chest and stomach. b. Look for the chest to rise and fall. c. Listen for air escaping during exhalation. d. Feel for the flow of air on the side of your face. e. Count the number of respirations for 15 seconds. Grader will state, "Casualty is not breathing". 5. Insert an NPA. a. Keep the casualty in a face-up position. b. Select the appropriate size of airway by measuring from the patient's nostril to the earlobe or from the patient's nostril to the angle of the jaw. c. Lubricate the tube of the NPA. d. Push the tip of the casualty's nose upward gently. e. Position tube of the NPA so that the bevel (pointed end) of the NPA faces toward the septum (the partition inside the nose that separates the nostrils). Most NPAs are designed to be placed in the right nostril. f. Insert NPA into the nostril and advance it until the flange rests against the nostril. Never force the airway into the patient's nostril. If resistance is met, pull the tube out and attempt to insert it in the other nostril. g. Recheck breathing per step 4. Grader will state, "Casualty is still not breathing". 6. Give breaths to ensure an open airway. a. Insert a face shield, if available, into the casualty's mouth, with the short airway portion over the top of the tongue, and flatten the plastic sheet around the mouth. b. Maintain airway and gently pinch nose closed (covering the NPA), using the hand on the casualty's forehead. c. Take a normal breath and place your mouth, in an airtight seal, around the casualty's mouth. d. Give two breaths (1 second each), taking a breath between them, while watching for the chest to rise and fall and listening and/or feeling for air to escape during exhalation. Breaths should not be over exaggerated or forceful. Grader will state, "The chest did not rise". e. Reposition the casualty's head slightly farther backward and repeat the breaths. Grader will state, "The chest did not rise". 7. Perform chest compressions to clear the airway. a. Kneel close to the side of the casualty's body. b. Locate the nipple line placing the heel of one hand on the lower half of the sternum (breastbone). c. Place the heel of the other hand on top of the first hand on the lower half of the breastbone, extending or interlacing the fingers. d. Straighten and lock the elbows with the shoulders directly above the hands. e. Without bending the elbows, rocking, or allowing the shoulders to sag, apply enough pressure to depress the breastbone 1½ to 2 inches. Give compressions at a rate of 100 per minute (hard and fast at a ratio of 30 compressions to 2 breaths) with the intent of relieving the obstruction. f. Look in the mouth for objects between compressions and breaths. After one round of compressions and breaths, the Grader will state, "You see an object in the casualty's mouth". g. Remove the object. Candidate simulates using proper technique. 8. Reopen airway and repeat the breaths (Steps 3 & 4). Grader will state, "You see the chest rise and fall with your breaths, but the casualty is still not breathing". 9. Check for a pulse for five to 10 seconds. Place tips of index and middle fingers in groove in casualty's throat beside the Adam's apple on the side closest to you. Do NOT use the thumb. Grader states, "You do not feel a pulse". 10. Perform CPR. a. Position your hands and body for chest compressions as in step 7. b. Give 30 compressions. 1. Press straight down to depress the breastbone 1 ½ to 2 inches. 2. Come straight up and completely release pressure on breastbone to allow chest to return to its normal position. The time allowed for release should equal the time required for compression. 3. Give 30 compressions in about 23 seconds (at a rate of 100 per minute). Do NOT remove the heel of your hand from the casualty's chest or reposition your hand between compressions. However, all pressure must be released from the chest cavity to allow for full chest wall expansion. c. Give two breaths. 1. Open the casualty's airway. 2. Give two breaths (1 second each). d. Repeat steps 10a-c for five cycles or two minutes. After one PROPERLY performed cycle, the Grader will state, "Two minutes has elapsed". If the Candidate does not perform the steps properly within two minutes, they will be a NO-GO. e. Reassess the casualty. 1. Check for the return of the pulse for 3 to 5 seconds. Grader will state, "You feel a pulse". 2. Check breathing for 3 to 5 seconds. Grader will state, "Casualty is not breathing". f. Give breaths at the rate of one every 5 to 6 seconds (10 to 12 breaths per minute). Note: Breaths should not be over exaggerated or forceful. After the Candidate has demonstrated PROPER performance, Grader will state, "Two minutes has elapsed". If the Candidate does not perform the steps properly within two minutes, they will be a NO-GO. g. Recheck for pulse and breathing. Grader will state, "The casualty is breathing and conscious". 11. Place the casualty in the recovery position (by rolling him/her as a single unit onto his/her side, placing the hand of his/her upper arm under his/her chin, and flexing his/her upper leg) until help arrives. Watch the casualty closely for life-threatening conditions, maintain an open airway, and check for other injuries. 12. Candidate will state that if the casualty's condition deteriorates, they will continue CPR until: a. The breathing and pulse returns. b. They are relieved or stopped by a qualified person. c. They are physically unable to continue.

M9: Treat an Open Abdominal Would and Eye Injury

1. Check for both entry and exit wounds (there should only be one) by sitting casualty up or rolling to the side. 2. Position the casualty on back, flex knees, and turn head to side, keeping airway clear in case of vomiting. 3. Expose the wound. Pick up organs that are on ground using a clean, dry dressing and gently place on abdomen without touching them. Do not probe/clean/try to remove foreign objects from or push organs back inside body. 4. Apply a moist, sterile abdominal dressing. If an object is extending from wound, do not remove it. Place as much of wrapper over wound as possible without dislodging or moving. Do not place wrapper over object. a. Ensure dressing is large enough to cover entire mass of protruding organs or area of the wound. b. If large enough to cover affected area, place sterile side of plastic wrapper directly over wound. c. Place dressing directly on wound or plastic wrapper if used. Do not apply pressure or expose internal parts. d. Tie dressing tails loosely at casualty's side or secure hooking ends of closure bar into bandage. e. Repeat if two dressings are needed. Ensure that ties of additional dressings are not tied over each other. f. Ensure dressing is secured firmly enough to prevent slipping, without applying pressure. 5. Treat for shock. a. Loosen binding clothing and prevent the casualty from getting chilled or overheated. While performing this step, the Grader will state, "The casualty is making vomiting sounds". b. Roll to side without causing further injuries. Grader will state, "Vomiting has stopped". c. Return to supine position with knees flexed. Re-secure bandages and blanket if needed. 6. Treat lacerations and contusions of tissue surrounding the eye (Grader prompt if not simulated). a. Close the lid of the affected eye. Do not exert pressure or manipulate the globe in any way. b. Cover the injury with moist, sterile dressing to prevent drying. c. Cover torn eyelids with a loose dressing. Place field dressing over eye pad or dressing. 7. Treat injury to the eyeball (Grader prompt if not simulated). Do not reposition the globe or replace it in the socket. a. Cover injured eye with a sterile dressing soaked in saline to keep the wound from drying. b. Place a field dressing over eye pad. Tell the casualty not to squeeze the eyelids together. 8. Treat extrusion (Grader prompt if not simulated). a. Cut a hole in several layers of dressing material and then moisten it with saline. b. Place dressing so globe protrudes through hole without touching it. Build up dressing higher than globe. c. Apply Fox eye shield or improvised object such as a paper cup, structural aluminum malleable (SAM) splint, or intact set of eyewear secured in place. 1. Apply garter shield cover or tape to edges of Fox eye shield or object. 2. Place over the injured eye, resting on the bony support of the face and secure with tape. 9. Treat protruding object (Grader prompt if not simulated): Immobilize object and dress with moist, loose dressing.

M8: Perform First Aid for an Open Head Wound in a CBRNE Environment

1. Check the casualty's level of consciousness by asking, "What is your name, where you, and what is today's date?" Grader states, "The casualty replies appropriately". 2. Position the casualty. a. Have the casualty sit up. b. Turn head to the side (opposite the wound) to prevent bleeding into the mouth. 3. Expose the wound by removing the casualty's helmet, if necessary, but retaining all MOPP garments. Do NOT attempt to clean the wound, remove a protruding object, or apply a pressure dressing. Do NOT put unnecessary pressure on the wound or attempt to push any brain matter back into the head (skull). Do NOT touch white (sterile) side of dressing or allow it to come into contact with any surface other than wound. 4. The following procedures are for applying a field dressing. If you are applying an emergency bandage, follow the procedure for other bleeding wounds, while observing general guidelines and precautions. a. Apply the casualty's dressing to a wound on the forehead or back of head. 1. Apply dressing, white side down, directly over wound with tails extending toward sides of head. 2. Wrap tails, one at a time, around head in opposite directions, making sure tails cover dressing but not eyes or ears. 3. Tie the tails at the side of the head using a nonslip knot. b. Apply the casualty's dressing to a wound on the top of head. 1. Apply the dressing, white side down, directly over the wound. 2. Wrap 1st tail under chin and bring up in front of ear over dressing above and in front of other ear. Note: Ensure tails remain wide and close to the front of the chin to avoid choking the casualty. 3. Wrap 2nd tail under chin in opposite direction and up the side of head to meet 1st tail. 4. Cross the tails. 5. Wrap one tail across forehead above eyebrows to a point just above and in front of opposite ear. 6. Wrap other tail above ear, low over back of head, and above opposite ear to meet the other tail. 7. Tie the tails using a nonslip knot. c. Apply the casualty's dressing to a wound on the side of the head or cheek. 1. Apply dressing, white side down, directly over the wound with the tails extending up and down. 2. Wrap the top tail over the top of the head, down in front of the ear, under the chin, and up over the dressing to a point just above the ear. 3. Wrap the other tail in the opposite direction to meet the first tail. 4. Cross the tails and complete the procedure as follows: a. Wrap 1st tail across forehead above eyebrows to a point above and in front of opposite ear. b. Wrap the 2nd tail above ear, low over back of head, and above opposite ear to meet 1st tail. c. Tie the tails using a nonslip knot. 5. Watch the casualty for life-threatening conditions, check for other injuries, and treat for shock. Seek medical aid.

M5: Control Bleeding

1. Perform a blood sweep of the extremities, neck, armpits, and groin areas. Expose wounds if bleeding is detected. If the second wound is not simulated, the Grader will identify the location during the blood sweep. If the Candidate fails to sweep that area or detect the wound, they are a NO-GO. 2. Apply a hemostatic dressing to the major non-arterial wound that is bleeding heavily. a. Remove all clothing or equipment to obtain access to the wound. b. Identify the point of bleeding within the wound. Remove any pooled blood from the wound cavity with your hand or a wad of cotton gauze. Locate the bleeding vessel(s). c. Pack Combat Gauze directly over the source of bleeding; pack the wound with the entire dressing. d. Apply direct pressure for 3 minutes; periodically check dressing to ensure placement and bleeding control. When performed correctly, Grader will state, "Three minutes has elapsed and wound is still bleeding". e. Pack second Combat Gauze into wound. When performed correctly, Grader will state, "Bleeding is under control". f. Bandage wound to secure the dressing in place. 1. Apply cotton gauze (either wad or rolled) over the dressing. 2. Secure in place with an emergency bandage, elastic bandage, tape, or other type available. 3. Reassess any tourniquets placed during Care under Fire to ensure they are still effective. Grader will state, "The wound spurts blood when the limb is moved". a. Attempt to further tighten the CAT until bleeding stops. Candidate will verbalize this and will ensure to not overtighten if using an actual Soldier as a casualty. Grader will state, "The CAT is still ineffective". b. Place a second CAT, from the casualty's IFAK, side-by-side but above the other tourniquet 1. Pull free end of self-adhering band through buckle and route through friction adapter buckle. On an arm wound, it is not necessary to route the strap through the friction adapter. 2. Pull self-adhering band tight around extremity and fasten it back on itself as tightly as possible. 3. Twist the windlass until the bleeding stops. Candidate will verbalize this and will ensure to not overtighten if using an actual Soldier as a casualty. 4. Lock the windlass in place within the windlass clip and secure the windlass with the windlass strap. 5. Assess for absence of a distal pulse. Candidate should perform and verbalize with proper technique. Pulse must be taken with skin to skin contact and not using their thumb. 6. Place a "T" and the time of the application on the casualty with a marker (provided in casualty's IFAK). This can be simulated and verbalized, or a piece of lamination can be applied to the casualty's forehead so each Candidate can perform the task. 7. Secure the CAT in place with tape (provided in casualty's IFAK). 8. Apply a pressure or hemostatic dressing.

M10: Treat a Fracture and a Burn

1. Reassure casualty and explain the process of treating the fracture, loosen tight/binding clothing, and remove jewelry from limb, placing in casualty's pocket. 2. Check for signs of circulation problems below injury. Grader prompts. Check light-skinned persons for skin color (pale, white, or bluish gray). Check dark-skinned persons by depressing toenail or fingernail beds and seeing how fast the color returns. A slower return of color to the injured side indicates a circulation problem. Feel injured arm or leg to see if it is colder than the uninjured one. Ask about presence of numbness, tightness, or cold sensation. 3. Splint-improvised or SAM splint (Grader choice). SAM splints do not require padding (no femur fractures). Improvised splints are made from two rigid objects. Use improvised materials to secure the rigid objects/keep fracture immobilized. Use improvised materials to pad the splints. If splinting materials are not available, use the chest wall to immobilize a suspected fracture of the arm and the uninjured leg to immobilize the fractured leg. a. As a rule, splint fracture in position found. If no circulation below fracture site or limb is grossly angulated/you cannot effectively splint it, you may need to gently realign it. Grader prompt. With one hand supporting fracture site, use other to grasp part of limb farthest from fracture and gently pull traction. b. Ensure ends of splints do not press against groin. Pressure could interfere with blood circulation. c. Place one splint on each side of arm/leg and pad appropriately. Make sure splints reach beyond joints above and below fracture. A single SAM splint may be used for small fractures such as wrist. d. Tie nonslip knots on splint with improvised or actual cravats. Do not tie cravats directly over the fracture. Gently place at least two cravats above and two cravats below the fracture if possible. e. Check splint for tightness. Make sure cravats are tight enough to hold splinting materials securely in place. Recheck circulation below injury to make sure that circulation is not impaired. Make any adjustments to improve circulation without allowing splint to become ineffective. 4. Sling-actual or improvised (Grader choice). Make an improvised sling from non-stretching material. a. Ensure supporting pressure is on uninjured side and hand of supported arm is slightly higher than elbow. b. Recheck circulation below the injury to make sure that circulation is not impaired. c. Make any adjustments to improve circulation without allowing the sling to become ineffective. 5. Swathe (Grader choice). Apply when there is a splinted fracture of elbow/leg or when fracture cannot be splinted. a. Place swathes above and/or below the fracture, not over it. b. Apply swathes to arm by wrapping over injured arm, around casualty's back, and under arm on uninjured side. Tie ends on uninjured side. c. Apply swathes to injured leg by wrapping swathes around both legs and tying on uninjured side. d. Recheck circulation below the injury to make sure that circulation is not impaired. e. Make any adjustments to improve circulation without allowing the swathe to become ineffective. 6. Treat burn. a. Cut casualty's clothing away from burns and remove potentially constricting items such as rings/bracelets. b. Apply a dry sterile dressing securely but not overly tight. Cover extensive burns with a sterile sheet/linen.

M4: Evaluate a Casualty for Heat Injury

1. Type: Heat cramps. a. Signs and symptoms: 1. Muscle cramps of the arms, legs, and/or abdomen. b. Treatment: 1. Move to shaded area and rest. 2. Loosen clothing. 3. Oral rehydration. 2. Type: Heat exhaustion. a. Signs and symptoms: 1. Profuse sweating and pale/gray/moist/cool skin. 2. Headache. 3. Weakness. 4. Dizziness. 5. Temperature as high as 104 degrees. b. Treatment: 1. Move the casualty to a shaded area and provide oral rehydration unless nauseated. 2. Loosen and/or remove the casualty's clothing and boots. 3. Pour water on the casualty and fan him/her if possible. 4. Cover with ice sheet; elevate legs. 3. Type: Heat stroke. a. Signs and symptoms: 1. Core temperature rising above 106 degrees within 15 minutes. 2. Hot, dry skin. 3. Headache. 4. Dizziness. 5. Nausea. 6. Confusion. 7. Weakness. 8. Pulse and respirations are weak and rapid. Treatment heat stroke: 1. Call for evacuation. Candidate verbalizes. 2. Cool the casualty with any means available, even before taking the clothes off (Unit SOP). 3. Remove the casualty's outer garments and/or protective clothing. 4. Lay the casualty down and elevate his/her legs. 5. Place ice sheets/packs in groin, armpits, and around neck. 6. Immerse the casualty in cold water or pour cold water on the casualty if available. 7. Cover all but the face with a soaked ice sheet. 8. Evacuate the casualty. Candidate verbalizes.

M6: Evaluate and Treat a Casualty for a spinal Injury and Shock. Apply a Cervical Collar, Treat for Shock, and Prepare for Transfer

Apply a Cervical Collar, Treat for Shock, and Prepare for Transfer: 1. Apply Cervical Collar a. Have the other Soldier kneel at the casualty's head and manually apply in-line stabilization of the head and neck. If the assistant is notional, the Grader will state, "The other Soldier has the head and neck in-line and immobilized". b. Reassure the casualty and explain the procedure to him/her. c. Measure and determine the size of collar to apply. 1. The front height of the collar should fit between the chin and the chest at the suprasternal notch. 2. Once in place, the collar should rest on the shoulder girdle and provide firm support under both sides of the mandible without obstructing the airway or any ventilation efforts. 3. If the collar is too large, the casualty's neck may be placed in hyperextension. 4. If the collar is too small, the casualty's neck may be placed in hyperflexion. d. Size the collar based on the manufacturer instructions. e. Apply the collar to a supine casualty. 1. Ensure the other Soldier maintains in-line stabilization. 2. Set the collar in place around the neck. 3. Secure the Velcro strap in place. 4. Maintain manual stabilization of the head and neck until the casualty is immobilized on a long spine board. If the assistant is notional, the Grader will state, "The other Soldier has the head and neck immobilized". 5. Immobilize casualty to spine board using straps and head immobilization blocks (or improvise). 2. Assess for shock. a. Assess casualty's level of consciousness. Grader will state, "Casualty does not answer, but reacts to pain". b. Evaluate skin. Grader will state, "Skin is pale and moist; abdomen is distended". c. Assess capillary refill on a finger. Grader will state, "Capillary refill takes four seconds". d. Check for pedal pulse (skin to skin; no thumb). Grader will state, "You do not feel a pulse". e. Check for femoral pulse (skin to skin; no thumb). Grader will state, "You do not feel a pulse". f. Check for radial pulse (skin to skin; no thumb). Grader will state, "You do not feel a measurable pulse". g. Check for carotid pulse (skin to skin; no thumb). Grader will state, "You feel a weak but rapid pulse". h. Measure pulse for 30 seconds (skin to skin; no thumb). Grader prompt if using a mannequin. i. Assess respirations. Grader will state, "Respirations are rapid but shallow". j. Measure respirations for 30 seconds. Grader prompt if using a mannequin. 3. Treat for hemorrhagic shock. a. Position the casualty. 1. Move the casualty under shelter to shade him/her from direct sunlight. Note: Secure casualty to the litter before moving. If no assistant is available, Candidate will verbalize, but still ensure to secure the casualty on the litter. 2. Maintain supine position and spinal immobilization. b. Loosen clothing at the neck, waist, or anywhere it is binding. c. Prevent the casualty from getting chilled or overheated. Using a blanket or clothing, cover the casualty to avoid loss of body heat by wrapping completely around the casualty, underneath the litter straps. Re-secure the patient on the litter. d. Calm and reassure the casualty; watch the casualty closely for life-threatening conditions. 4. Correctly record all treatments on the front and back of the TCCC Card. a. Evacuation (EVAC) -Mark an "X" on the casualty's evacuation priority/precedence (Urgent; Priority; Routine). b. Date - Write date of injury in DD-MMM-YY format. For example, "29-JUN-13". c. Time - Write 24 hour time of injury, and indicate whether local (L) or Zulu (Z) time. For example, "1300Z". d. Mechanism of Injury - Mark an "X" on the mechanism or cause of injury (artillery, blunt, burn, fall, grenade, gunshot wound (GSW), improvised explosive device (IED), landmine, motor vehicle crash/collision (MVC), rocket propelled grenade (RPG), other (specify)). Mark all that apply. e. Injury - Mark an "X" at the site of the injury (ies) on the body picture. If multiple mechanisms of injury and multiple injuries, draw a line between the mechanism of injury and the anatomical site of the injury. (Spinal injury and internal bleeding). f. Time - Write time of vital signs taken. g. Pulse (rate & location) - Write casualty's pulse rate. h. Respiratory Rate - Write casualty's respiratory rate. i. AVPU - Write casualty's level of consciousness (AVPU: Alert, Verbal, Pain, Unresponsive). j. Evacuation (EVAC) -Mark an "X" on the casualty's evacuation priority/precedence (Urgent; Priority; Routine). k. Other - Mark an "X" for other treatments administered (combat pill pack, eye shield (mark right (R) or left (L)), splint, hypothermia prevention) and type of device(s) used. (Cervical collar). l. Notes - Use this space to record any other pertinent information and/or clarifications. (Patient exhibiting signs and symptoms of shock). m. First Responder Name - Print the first responder's name (Last, First). n. First Responder Last 4 - Write last four numbers of first responder's Social Security number. o. Secure the TCCC Card to the casualty per Unit SOP.

M2: Provide care Under Fire and Move a Casualty

Care under Fire: Time starts when the Grader says that fire suppression has been achieved. 1. Return fire and take cover until fire suppression is achieved. a. Candidate will return fire, move to cover, and yell distance, direction, and description. b. Direct the casualty to return fire, move to cover, and administer self-aid to stop the bleeding. When the Candidate has demonstrated the proper techniques, the Grader will state "Fire suppression has been achieved", or the enemy fire will stop. c. Candidate states, "Cover me". Grader will reply, "Got you covered". 2. Move the casualty, his/her weapon, and mission-essential equipment to cover using the Cradle-drop drag (below), or any appropriate technique, without causing further injuries or losing any equipment. a. With the casualty lying on his/her back, kneel at the head. b. Slide your hands, palms up, under the casualty's shoulders getting a firm hold under his/her armpits. c. Partially rise, supporting the casualty's head on one of your forearms. You may bring your elbows together and let the casualty's head rest on both of your forearms. d. With casualty in a semi-sitting position, rise and drag backwards to the nearest covered position. 3. Administer life-saving bleeding control by applying the CAT to the wounded extremity. a. Expose the wound and remove the CAT from the casualty's IFAK. b. Place CAT, 2-3 inches above the wound on the injured extremity. c. Pull the free end of the self-adhering band through the buckle and route through the friction adapter buckle. d. Pull the self-adhering band tight around the extremity and fasten it back on itself as tightly as possible. e. Twist the windlass until the bleeding stops. Candidate will verbalize this, and will ensure to not overtighten if using an actual soldier as a casualty. f. Lock the windlass in place within the windlass clip. g. Secure the windlass with the windlass strap. h. Assess for absence of a distal pulse. Candidate should perform and verbalize with proper technique. Pulse must be taken with skin to skin contact and not using their thumb. i. Place a "T" and the time of the application on the casualty with a marker (provided in casualty's IFAK). This can be simulated and verbalized, or a piece of lamination can be applied to the casualty's forehead so each candidate can perform the task.

M6: Evaluate and Treat a Casualty for a spinal Injury and Shock. Identify Signs and Symptoms of Shock

Identify Signs and Symptoms of Shock: 1. Sweaty but cool skin. 2. Pale skin. 3. Restlessness or nervousness. 4. Thirst. 5. Severe bleeding. 6. Confusion. 7. Rapid breathing. 8. Blotchy blue skin. 9. Nausea and/or vomiting. 10. Low blood pressure. 11. Absence of distal pulse. 12. Capillary refill delayed more than three seconds.

M1: Request Medical Evacuation

Prepare the MEDEVAC request: 1. Determine grid coordinates for pickup, providing complete six digit grid with identifier, accurate within 200 meters. 2. Determine operational radio frequency, call sign, and suffix. Candidate uses SOI to determine necessary information. Candidate makes appropriate changes to radio and prepares for transmission on MEDEVAC frequency. 3. Determine number of patients and precedence. Candidate uses TCCC Cards to determine necessary information. 4. Determine special equipment required based on the site location, patient injuries, and additional guidance. 5. Determine number and type of patients. Candidate uses TCCC Cards to determine the necessary information. 6. Determine security of pickup site. Give this information to the Candidate during the Condition brief. 7. Determine method of marking the pickup site. Candidate must choose based on the choices given. 8. Determine patient nationality and status. Candidate uses TCCC Cards to determine the necessary information. The number of patients in each category need not be transmitted. 9. Determine terrain description based on site location/map/additional guidance. While only required in peacetime, it can be given as it will be transmitted on an encrypted frequency; it is used when not in a CBRNE environment. Transmit lines 1-5 using brevity codes: 1. Candidate states, "I have a MEDEVAC request". Grader provides a response within three seconds. 2. Line 1: Six digit grid, including grid zone identifier. 3. Line 2: Operational frequency, call sign, and suffix. Candidate will use this frequency later to transmit lines 6-9. 4. Line 3: A+#-Urgent, B+#-Urgent-Surgical, C+#-Priority, D+#-Routine, E+#-Convenience. States, "Break" between categories. 5. Line 4: A-None, B-Hoist, C-Extrication Equipment, D-Ventilator. 6. Line 5: L+#-Litter, A+#-Ambulatory. State, "Break" between categories. End transmission by stating, "Over". Transmit lines 6-9: 1. Candidate switches radio to operational frequency and regains contact with evacuation platform for transmission of remaining lines. Grader initiates contact, requesting remaining lines when Candidate switches radio frequency. 2. Line 6: N-No enemy in area, P-Possibly enemy in area, E-Enemy in area, X-Enemy in area (armed escort required). 3. Line 7: A-Panels, B-Pyrotechnic signal, C-Smoke, D-None, E-Other. 4. Line 8: A-U.S. military, B-U.S. citizen, C-Non-U.S. military, D-Non-U.S. citizen, E-Enemy prisoner of war. 5. Line 9: Provide description of pertinent terrain information. End transmission by stating, "Over".