Applying the Three Phases of Tactical Combat Casualty Care

Trauma care has been revolutionized by the concept of TCCC.

This is a preview of a feature article on developing tactical EMS protocols that appears in the February issue of EMS World Magazine. Click here to read the full article.

Developed for our armed forces, the ultimate goal of Tactical Combat Casualty Care (TCCC) is to contribute to our troops’ ability to continue their mission. This requires tactically trained paramedics as part of the combat team. The same concept can apply to civilian incidents, using the three zones of care defined by TCCC. These zones are based on potential cover, concealment, terrain, distance to threat, sniper coverage and effective firepower and provide guidance for which interventions are appropriate based on the potential threat.The three phases:

  • Care Under Fire: Characterized by the presence of an immediate direct threat, it’s the most dangerous time to deliver care. During this phase, the tactical operator would remain engaged with the perpetrators if possible. The tactical medic role: try to prevent further injuries to casualties; treat life-threatening bleeding; airway management is best deferred until the next phase.
  • Tactical Field Care: Injured people, once protected from immediate threat, receive limited Advanced Life Support (ALS) measures. Airway management should begin with Basic Life Support (BLS), but if that is not effective, surgical intervention could be needed. During this phase, tactical paramedics would seal sucking chest wounds, treat a tension pneumothorax, bandage wounds, splint fractures and work to prevent hypothermia.
  • TACEVAC. This phase is more traditional, with the EMS focus on transporting to definitive care. Paramedics would apply all ALS steps required, place chest tubes if needed, reassess wounds including those that required a tourniquet, provide advanced airway management and treat with analgesics and antibiotics.  

Protocols You Must Consider
Even in civilian situations, tactical paramedics may face a delay in getting patients to definitive care. Tactical paramedics must make appropriate risk/benefit determinations regarding safety and the medical interventions required. So, protocols must reflect the need to provide care under threatening conditions—or conditions that somehow limit response. They should include hemorrhage control and key aspects of keeping responders in a condition capable of continuing their mission. However, because different EMS systems have different resources and transport times, not all suggested protocol topics fit every department. Medical directors must determine which protocol topics are appropriate for their tactical medics.

Elliot D. Carhart, MHS, RRT, EMT-P, EMT-T, is an assistant professor of emergency services at Jefferson College of Health Sciences in Roanoke, VA. He is currently an EdD candidate at Nova Southeastern University, where his studies have focused on healthcare education. He is a former firefighter/paramedic, registered respiratory therapist, and has experience in tactical EMS and technical rescue. Contact him at