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Where appropriate, a minimum-better-best format is included for sit-
uations in which the operational reality precludes optimal care for a
given scenario:
■ Minimum: This is the minimum level of care which should be de-
livered for a specified level of capability
■ Better: When available or practical, this includes treatment strate-
gies or adjuncts that improve outcomes while still not considered
the standard of care.
FIGURE 1
Steps of PCC ■ Best: This is the optimal medical for a given scenario based on the
Principles. level of medical expertise of the provider
Expectations of prehospital care, based on TCCC’s role-based stan-
dard of care, are included within each section:

■ Tier 1: This is the basic medical knowledge for all service-members.
■ Tier 2: Those who have been through approved CLS training are
expected to be able to meet the standards at this level of care.
■ Tier 3 (Combat Medics/Corpsmen [CMC]): Those who are trained
medics/corpsmen are expected to meet the medical standards for
this tier.
5. Perform a teleconsultation. ■ Tier 4 (Combat Paramedic/Provider [CPP]): This is the highest
As soon as is feasible, the medic should prepare a teleconsulta- level of prehospital capability and will have a significantly ex-
tion by either filling out a preformatted script or by writing down panded scope of practice.
their concerns along with the latest patient information.
6. Create a nursing care plan. MASCAL/Triage – Dr Shelia Savell, CPO Tyler Scarborough
Nursing care and environmental considerations should be ad-
dressed early to limit any provider- induced iatrogenic injury. Background
7. Implement team wake, rest, chow plan. The foundation of effective PCC is accurate triage for both treatment
The medic and each of their first responders should make all in the PCC setting and for transportation to a higher level of care,
efforts to take care of each other by insisting on short breaks for as well as effective resource management across the entire trauma
rest, food, and mental decompression. system. Resource management includes the appropriate utilization of
8. Anticipate resupply and electrical issues medical and non-medical personnel, equipment and supplies, commu-
9. Perform periodic mini rounds assessments. nications, and evacuation platforms. Like most Mass Casualty inci-
Stepping back from the immediate care of the patient periodi- dents (MASCAL), the purpose of triage in a PCC setting is to swiftly
cally and re-engaging with a mini patient round and review of identify casualty needs for optimal resource allocation in order to
systems can allow the medic to recognize changes in the condi- improve patient outcomes. However, PCC presents unique and dy-
tion of the patient and reprioritize interventions. namic triage challenges while managing casualties over a prolonged
■ Is the patient stable or unstable? period with a low likelihood of receiving additional medical supplies
■ Is the patient sick or not sick? or personnel with enhanced medical capabilities apart from pre-es-
■ Is the patient getting better or getting worse? tablished networks. MASCAL in a PCC environment will necessitate
■ How is this assessment different from the last assessment? more conservative resource allocation than traditional MASCAL in
10. Obtain and interpret lab studies. mature theaters or fixed medical facilities where damage control sur-
When available, labs may be used to augment these trends and gery, intensive care, and medical logistical support are more readily
physical exam findings to confirm or rule out probable diagnoses. available, and resupply is more likely. PCC dictates the need for imple-
11. Perform necessary surgical procedures. menting various triage and resource management techniques to ensure
The decision to perform invasive and surgical interventions the greatest good for all. The objectives and basic strategies are the
should consider both risks and benefit to the patient’s overall out- same for all MASCAL; however, tactics will vary depending on the
come and not merely the immediate goal. available resources and situations.
12. Prepare for transportation or evacuation care. MASCAL Decision Points
If the medic is caring for the patient over a long tactical move or 1. Determine if a PCC MASCAL is occurring – do the requirements
strategic evacuation, they should be prepared with ample drugs, for care exceed capabilities?
fluids, supplies and be ready for all contingencies in flight. ■ What is the threat? Has it been neutralized or contained? If not,
13. Prepare documentation for patient handover.
security takes priority.
The preparation for transportation and evacuation care should begin ■ What is the total casualty estimate?
immediately upon assuming care for the patient and should include ■ Are there resource limitations that will affect survival?
hasty and detailed evacuation requests up both the medical and oper- ■ Can medical personnel arrive at the casualty location, or can
ational channels with the goal of getting the patient to the proper role the casualty move to them?
of care as soon as possible. ■ Is evacuation possible?
■ Communicate the situation to all available personnel conduct-
Guideline User Notes ing or enabling PCC.
PCC operational context uses the following paradigm for phases of ■ Assess requirements for which class of triage you are facing (see
care for different periods of time one is in a PCC scenario (see Table 1): Appendix C) and scale medical action to maximize lethality
then survivability.
TABLE 1 Roles of Care
■ Remain agile and be ready to move based on the mission.
Role Definition Time Period
2. Determine if conditions require significant changes in the commonly
1a Carried/Point of Need/Ruck <1 hr understood and accepted standards of care (Crisis Standards of
3
1b Mission-specific transportation platform/Truck 1–4 hr Care) or if personnel who are not ordinarily qualified for a particu-
1c Mission support site/House >4 hr lar medical skill will need to deliver care. MASCAL in PCC requires
1d Evacuation platform/Plane (as planned or available) No timeframe both medical and non-medical responders initially save lives and pre-
serve survivable casualties. Both groups will need skills traditionally

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