Two Casualties, One Aid Bag
A nine-soldier mounted patrol is 12 kilometers from the nearest base when an IED strikes the second vehicle. You are the senior combat lifesaver on the ground. The platoon medic is in the lead vehicle, 600 meters ahead, and is not answering the radio. Three soldiers are hurt.
- Soldier A, 24: traumatic amputation of the right leg above the knee. A buddy placed a tourniquet high on the thigh six minutes ago; the dressing is soaked and blood is pooling under the leg.
- Soldier B, 31: blast to the chest, sitting upright, struggling to breathe and speaking two words at a time. Breath sounds are absent on the left, the trachea is shifted right, and the radial pulse is weak and fast.
- Soldier C, 22: walking, ringing ears, minor facial lacerations, confused about where he is.
Your aid bag has two tourniquets, one vented chest seal, hemostatic gauze, one 14-gauge needle, and IV supplies. No blood products. The vehicle radio works; the medic's does not. Battalion is 20 minutes away by ground.
1. In what order do you treat these three casualties, and why does that order differ from the order in which they are screaming?
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Order of treatment: A, then B, then C - driven by MARCH, not by volume.
MARCH is Massive hemorrhage, Airway, Respiration, Circulation, Hypothermia/head injury. Within MARCH you treat the thing most likely to kill the patient in the next few minutes first.
- Soldier A first, briefly. He has a junctional amputation with a tourniquet that is not controlling bleeding. Uncontrolled arterial bleeding can kill in minutes. The intervention is fast - fix the tourniquet, then move on. He is also the one whose problem is cheapest to solve with what you have.
- Soldier B second and with the most attention. Absent unilateral breath sounds, tracheal shift, worsening distress, and hypotension are the classic picture of tension pneumothorax, and it is rapidly fatal. It is treatable in the field with a needle and a vented seal. He is quiet, but quiet is often worse than loud.
- Soldier C last, but not ignored. He is walking and talking, which means his airway and breathing are intact. Confusion after a blast needs a head-to-toe check, a mental-status baseline, and monitoring for deterioration, but he is not going to exsanguinate while you work.
Why not treat in the order they call out: pain and panic are poor triage tools. The patient who is loudest is protecting his airway and perfusing his brain. The patient who is quiet, hypoxic, or bleeding out under a dressing is the one who dies while you attend to the noisy one.
Resource logic: with one needle and one chest seal, you must decide quickly. The decision rule is treat the reversible lethal threat you can actually fix with what is in the bag, then reassess. Verify needle-decompression technique and site against your unit's current TCCC/CLS protocols before you use it.
2. Soldier A's tourniquet is still bleeding through. What do you do, and what is the reasoning behind the placement?
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Action: apply a second tourniquet, proximal to (above) the first, and tighten until bleeding stops.
A tourniquet that is bleeding through means one of three things: it is not tight enough, it is in the wrong place, or it has lost mechanical advantage. The correct response is not to loosen and reapply while blood is pooling - that restarts bleeding and wastes time - but to add a second device above the first, tighten it until the bleeding stops and the distal pulse is gone, and note the time clearly.
Reasoning on placement. Standard placement is 2-3 inches above the wound, not over a joint, with the windlass accessible. "High and tight" is a rapid field expedient for a proximal amputation or when the exact wound location is unclear, and it works - the tradeoff is more tissue loss and a higher chance of nerve injury. For an above-knee amputation, the bleeding source is the femoral artery, so the tourniquet must be above the amputation level and above the knee joint.
Practical points:
- Write the time on the tourniquet or the casualty card. Every handoff must know it.
- Do not cover the tourniquet with a dressing or blanket where the next provider cannot see it.
- Expect the casualty to report severe pain; that is not a reason to loosen it.
- If a tourniquet has been down for a long period and evacuation is delayed, only a physician-directed protocol should consider conversion - not a field decision made alone.
Then move on. Once the bleeding is controlled, Soldier A is stable enough to pause, and the pneumothorax patient becomes the priority. Fix the lethal problem, then re-triage.
3. How do you handle Soldier B's chest injury, and how do you build the MEDEVAC request for all three?
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Soldier B: decompress and seal, in that order of thinking.
Absent breath sounds on one side, tracheal deviation away from the affected side, severe respiratory distress, and hypotension point to tension pneumothorax. The treatment is needle decompression followed by a vented chest seal over the wound. Common sites are the second intercostal space at the midclavicular line or the fifth intercostal space at the anterior axillary line; use whichever your current protocol specifies, and use a long enough needle to reach the pleural space. Then reassess: if he does not improve, the needle may be clogged, misplaced, or the tension may be on the other side - re-examine rather than assume.
A vented seal matters. A fully occluded seal on a chest wound can convert an open pneumothorax into a tension pneumothorax. If only a non-vented seal is available, monitor closely and be ready to burp it per protocol.
Nine-line MEDEVAC, built deliberately:
- Location, using a grid, plus a visual marking method (smoke, IR strobe, VS-17 panel) - the bird needs to find you, not just know where you think you are.
- Radio frequency and call sign of the receiving station.
- Number of patients by precedence: A is urgent, B is urgent, C is priority or routine depending on his mental status.
- Special equipment required - hoist, extraction equipment, or none.
- Number of patients by type: litter versus ambulatory.
- Security at the pickup site.
- Method of marking.
- Nationality and status of patients.
- NBC contamination, if any.
Practical sequencing: transmit the nine-line early, even before all treatment is complete, because the aircraft's timeline is longer than yours. Then keep working. Confirm the grid back from the receiving station - a single transposed digit sends the aircraft to the wrong valley.