Care Under Fire

TASK: Tactically manage a simulated casualty in a care under fire situation.

CONDITIONS: Given a written situation concerning a casualty under combat conditions and possible responses.

STANDARDS: Select the correct response based upon instruction given in lesson.

Army’s Combat Lifesaver Course: Student Self-Study (PDF)

Care under fire is the first phase of tactical combat casualty care. In care under fire, you and the casualty are under hostile fire and you are very limited to the care you can provide. In fact, you may not be able to provide any care. Your combat duties remain your primary mission. Your first priority while under fire is to return fire. You
should render care to injured soldiers only when such care does not endanger your primary (combat) mission.


When you are under effective hostile fire and see a wounded soldier who is also under enemy fire, you should do the following.

a. Take cover and return fire.

b. Suppress enemy fire. Reducing enemy fire maybe more important to the casualty’s survival than any immediate treatment you can provide.

c. Try to keep the casualty from sustaining any additional wounds.

d. Direct or expect the casualty to remain engaged as a combatant.

e. Try to determine if the casualty is alive.

f. If the casualty can function, direct him to move to cover, return fire, and administer self-aid.

g. If the soldier has suffered an amputation or has serious bleeding from an extremity, direct him to apply the Combat Application Tourniquet from his Improved First Aid Kit (IFAK) over his uniform and above the wound.

h. If the casualty is unable to return fire or move to safety
and you cannot assist him, tell the casualty to “play dead.”

i. Communicate the situation to your unit leader.


If you determine that you can provide assistance to the casualty under enemy fire, take the following actions before approaching a casualty on the battlefield. Remember to protect yourself.

a. Scan the area for potential danger.

(1) Survey the area for small arms fire.

(2) Survey the area for fire or explosive devices.

(3) Determine threat for chemical or biological agents.

(4) Survey buildings, if any, for structural stability.

b. Determine the best route of access to the casualty and the best route of egress. If you need to move the casualty to a safer area, be sure to select an area that provides optimum cover and concealment. Plan your evacuation route prior to exposing yourself to possible hostile fire.

c. Request covering fire during movement to and from the casualty’s location to reduce the risk to yourself and the casualty.

d. Anticipate the type of injuries the casualty may have received and what care will probably be needed. Did the casualty fall from a wall? (If so, the casualty may have broken bones.) Was there an explosion? (If so, the casualty may have blast effects.) Was there small arms fire? (If so, the casualty may have bleeding wounds.)

e. Anticipate how your actions (movement, noise, light, and so forth) may affect the enemy’s fire.

f. Decide what care you can administer when you reach the casualty and what care will have to wait until you have moved the casualty to a place of safety.


If the casualty cannot move himself to a place of safety and the combat situation allows you to safely assist the casualty, quickly evaluate the casualty, control any life-threatening bleeding from the extremities, and move the casualty and yourself to a safe location.

a. Approach the casualty by the safest route.

b. Form a general impression as you approach the casualty (extent of injuries, chance of survival, and so forth).

c. Upon reaching the casualty, determine his responsiveness (paragraph 2-5 below).

d. If the casualty has an amputation of a limb or live-threatening bleeding from a wound on a limb, quickly apply a tourniquet
(paragraph 2-6 below and paragraph 4-10 of Lesson 4).

e. Move the casualty and yourself to a place of safety where you can perform tactical field care (paragraph 2-7). When moving the casualty, take the casualty’s weapon and other mission-essential equipment with you if possible.

f. Listed below are some situations in which you should avoid treating the casualty while under fire.

(1) Your own life is in imminent danger.

(2) There are other soldiers in your area who require treatment more urgently.

(3) The casualty does not have vital (life) signs; that is, the casualty is not breathing, does not have a pulse, and is not moving.


NOTE: You may need to wait until you can safely provide tactical field care to fully perform this procedure.

a. Upon reaching the casualty, check the casualty for responsiveness.

(1) Ask in a loud, but calm, voice: “Are you okay?” Gently shake or tap the casualty on the shoulder.

(2) If the casualty is conscious, ask where it hurts or where his body feels different from usual. This helps to determine the level of consciousness and provides you with information that can be used when treating the casualty.

b. Ask the casualty questions to determine his level of consciousness. Ask the casualty questions that require more than a “yes” or “no” answer. Examples of such questions are: “What is your name?”, “What is the date?”, and “Where are we?”

(1) The AVPU scale is used in determining the casualty’s level of
consciousness. The four levels used in the AVPU scale are given below.

(a) A–The casualty is alert (knows who he is, the date, where he is,
and such).

(b) V–The casualty is not alert, but does responds to verbal (oral)

(c) P–The casualty responds to pain, but not to verbal commands.

(d) U–The casualty is unresponsive (unconscious).

(2) The following are some guidelines to use when assessing the casualty’s level of consciousness.

(a) A casualty who is yelling at you, telling you where the enemy fire is coming from, or performing similar actions is alert.

(b) If the casualty is alert or responds to voice, do not check the
casualty’s response to pain.

(c) To check a casualty’s response to pain, rub his breastbone (sternum) briskly with your knuckle.


Quickly check the casualty for potentially life-threatening hemorrhaging (severe arterial bleeding) from an extremity. For example, the shirt sleeve or pant leg may be red from bleeding. If severe bleeding is found, quickly apply a tourniquet high on the
injured limb over the uniform and tighten it to stop arterial bleeding (see Section II of Lesson 4). Remember, bleeding from a wound on
the extremity is the greatest cause of preventable death on the battlefield (paragraph 1-4).

a. If the casualty has an amputation of the arm, forearm, thigh, or leg, apply a tourniquet even if the wound does not show serious hemorrhaging. The body’s natural defenses may control the bleeding initially, but severe hemorrhaging will soon occur.

b. Do not waste time trying other techniques to control bleeding, such as a pressure dressing. Once you have reached a safe location, the tourniquet can be reevaluated and other techniques can be applied, if appropriate (see paragraph 2-8a),


After you have taken measures to control major hemorrhaging, you should seek safe cover for you and the casualty. If the casualty cannot move on his own or needs assistance, use a manual drag or carry. So me examples of manual drags and carries are given below. Once you and the casualty are in a safe location, you have moved
from the care under fire phase to the tactical field care phase. See Lesson 9 for additional information on drags, manual carries, and drag equipment.

a. Drags.

Drags are used to move a casualty quickly for a short distance. Figures 2-1, 2-2, and 2-3 illustrate some of the drags used. A two-person drag (figure 2-2) can move a casualty easier and quicker,
but exposes two soldiers to enemy fire.

Moving Wounded Soldier

b. Carries.

Carries involve lifting the soldier from the ground. The Hawes carry (figure 2-4) is the preferred one-person carry for moving a soldier. If the casualty is conscious and can assist, the one-person support carry (figure 2-5) may be used.

One-person carry techniques

Remember, a casualty with all of his gear may weigh around 300 pounds. A two-person carry, such as the modified two-person fore-and-aft carry (figure 2-6) or the two-person support carry (figure 2-7), can sometimes be used, but they are difficult and will expose another soldier to enemy fire.

Two-person carry techniques


Initiate tactical field care when you and the casualty are no longer under direct enemy fire. In tactical field care, you have more time to provide care. However, the tactical situation can change and you could find yourself back in a care-under-fire situation. In tactical field care, available medical equipment and supplies are limited to that carried into the field by the combat lifesaver and individual soldiers. Tactical field care is discussed in greater detail in Lesson 3. However, the procedures for performing tactical field care following care under fire are briefly discussed below.

a. Reassess Tourniquet, if Appropriate. If you treated the casualty in a care-under-fire situation and applied a tourniquet to stop bleeding on an extremity, reassess the bleeding.

(1) Expose the wound and determine if a tourniquet is actually needed.

(2) If a tourniquet is necessary, apply a second tourniquet directly on the patient’s skin two to four inches above the wound and tighten it (see Section II of Lesson 4). After the second tourniquet is applied, remove the original tourniquet that you applied over the injured soldier’s uniform.

(3) If a tourniquet is not necessary, use a pressure dressing, direct pressure, elevation, and/or a hemostatic agent such as Combat Gauze™ to control the bleeding, then remove the tourniquet (see Section I of Lesson 4). By converting the tourniquet to a pressure dressing or controlling the bleeding by other methods, you may be able to save the casualty’s limb.

WARNING: If tourniquet has been in place for more than six hours, do not attempt to remove the tourniquet. Removing a tourniquet after six hours should only be performed by medical personnel.

b. Check for Life-Threatening Hemorrhage. Check the casualty for any untreated wounds on the extremities that are life-threatening and treat them. See Lesson 4.

c. Continue to Evaluate and Treat. Continue to evaluate and treat the casualty,

(1) Take measures to maintain the casualty’s airway, including inserting a nasopharyngeal airway if needed. See Lesson 5.

(2) Treat any open chest wounds. See Section I of Lesson 6.

(3) Continue to treat other injuries (splint fractures, bandage other wounds, and so forth).

(4) Administer pain medications and antibiotics (combat pill pack). Use the casualty’s combat pill pack. Do not use your own pack since you may need them yourself and you have no extra combat pill packs in your aid bag.

(5) Take measures to prevent and treat shock (paragraph 3-12 of Lesson 3).

d. Communicate the Situation. Communicate the medical situation to the unit leader.

(1) Send a soldier for medical help (combat medic), if appropriate.

(2) Let the unit leader know if the casualty will not be able to continue his mission.

e. Monitor the Casualty. Monitor the casualty’s level of consciousness and breathing.

(1) Recheck the casualty’s level of consciousness (AVPU scale) about
every 15 minutes to determine if the casualty’s condition has changed. Maintaining a check on the casualty’s level of consciousness is especially important if the casualty has suffered a head injury.

(2) If the casualty has an open chest wound, is having trouble breathing, and the difficulty in breathing is increasing, perform needle chest decompression (see Section II of Lesson 6).

(3) Let the unit leader know if there is any significant change in the casualty’s status.

f. Prepare Casualty for Evacuation, if Needed.

(1) Record your evaluation and treatment on a Field Medical Card, Tactical Combat Casualty Care Card, or similar document. Attach the document to the casualty’s clothing or place it in an appropriate pocket on the casualty (Lesson 7).

(2) Request a medical evacuation (MEDEVAC), if appropriate (Lesson 8).

(3) Evacuate a casualty using nonmedical means (CASEVAC), if needed (Lesson 9 and Lesson 10).

(4) Continue to monitor the casualty and keep the unit leader informed of any major change in the casualty’s condition.