Almost a decade ago, before Russia invaded Ukraine or even Crimea, I wrote about a Ukrainian medic named Oleysa Zhukovskaya, a young woman who volunteered as a medic at protests against the Pro-Russian government at the time.
In the midst of the action, she tweeted the words: “I am dying.” You see, the government used snipers to target medics and journalists. With an armband sporting a red cross, she was a natural target. She took a round to the neck.
Seeing this drama unfold, I considered long term survival scenarios in which civil unrest and other events may put a survival group’s medic in harm’s way. This may involve situations where the medic is foraging with his/her group or simply at “base camp” when hostile forces arrive.
In Kiev, the young woman might have thought her red cross identified her as a “non-combatant” and made her immune to enemy fire. Despite the Geneva Convention, this probably could not be further from the truth: Eliminating the medics is a great way to decrease the effectiveness of the group and is a devastating hit to morale. US military medics today wear a much less noticeable insignia.
Doing the right thing at the right time is the cornerstone of tactical combat casualty care (TCCC). This is different from what you might consider to be the practice of good medicine. In an unsafe environment, good medicine could be bad tactics, and that could get people killed.
When under fire, therefore, your priorities should be to:
- Return fire and take cover. This poses the question: Should medics be armed? Gosh-darn right they should. Your goal is to abolish all threats, and this means helping to provide suppressive fire if needed. The best medical care when under fire is eliminating the enemy, or at least keeping their heads down and weapons silent.
This tactic may be problematic for the medic, as they will want to attend to wounded members first. Without dealing with the threat, however, by running into the line of fire, they’re likely to become the next casualty. History shows us that this was a common way for medics to meet their end, sometimes on the way to evaluate casualties already beyond help.
Keep the casualty engaged in returning fire
- Direct the casualty to remain engaged as a combatant if appropriate. An exception is if mental status is altered due to wounds, concussion, or other injuries. In this case, it’s better to disarm the casualty.
- If you can’t reach the casualty, direct them to move to cover and apply self-aid using their individual first aid kit (IFAK). Each of the members of your group should have one. If you can reach the casualty without becoming one yourself, extract them to the relative safety of cover immediately, so as to avoid sustaining additional wounds.
- Stop life-threatening hemorrhage if possible. Use a CoTCCC-recommended tourniquet for wounds anatomically amenable to tourniquet use. Apply the limb tourniquet over the uniform clearly above the bleeding site. If the site of bleeding is not readily apparent, place the tourniquet “high and tight” (as high on the extremity as possible) and move the casualty to cover.\
- Transport your victim away from hostile forces as soon as possible.
Get the casualty and yourself to cover asap
Notice I haven’t mentioned airway management or cervical spine immobilization, two basic steps in evaluation, care, and transport of victims of trauma in a safe environment. This is good medicine, but control of hemorrhage will be the most likely way you’ll save a life in this scenario. You don’t have the luxury of time to do much else. That part happens when all is clear, and is called tactical field care. We’ll discuss what to do next in future articles.
A complex issue facing the medic is that many tools used to evaluate a victim might be useless in a firefight. Forget trying to listen to a casualty with a stethoscope if there is gunfire. As well, it’s foolhardy to use a head lamp at night to treat the wounded, as it might as well be a target bull’s-eye.
Something that was clear to me in these settings was the importance of cross-training. Everyone in your group should know how to apply a tourniquet correctly to themselves and others, as well as other basic hemorrhage control strategies. If the medic is the wounded party, the ability to give concise instructions to others under stress could save a life (yours!).
If you are the medically responsible member of your group, think about what you would tell other group members to do if you were bleeding, broke a bone, were sick, etc. The more people that know how to deal with medical issues, the higher the chances to succeed, even if everything else fails.
I have the highest respect for the combat medic, who has a tough job in the best of circumstances. Each one of them is a better man/woman than this old country doctor. To see what goes into becoming one, see these first-person accounts:
By the way: Our Ukrainian medic was transported to the hospital, and survived. The last information I have on her is from 2021, before the Russian invasion. Given the situation, I can’t say if she lives today. If you know, please contact me.
Joe Alton MD
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