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In the Direct Threat (Care Under Fire) phase, provider and patient survivability under active threat governs all decisions. The TCCC/TECC framework prioritizes returning effective fire, using cover/concealment, and addressing immediately fatal problems that can be corrected quickly. Massive external extremity hemorrhage is the leading preventable cause of death in this setting; therefore, rapid tourniquet application—high and tight if the exact site is obscured—is the intervention with the greatest survival impact that can be performed in seconds while moving to cover. Airway maneuvers, full MARCH sequence, and vascular access are deferred until the Indirect Threat/Tactical Field Care phase when the tactical situation allows. Attempting airway devices or IVs while exposed increases risk to the team and delays definitive hemorrhage control. Once in relative safety, reassess the tourniquet, convert to a pressure dressing if appropriate, and proceed through MARCH (Massive hemorrhage, Airway, Respiration, Circulation, Hypothermia/Head injury), but in Direct Threat the life-saving priority is controlling catastrophic bleeding with a tourniquet as rapidly as possible.

Ketamine is safe and effective when titrated to effect with continuous monitoring of airway, breathing, circulation, and mental status. Prepare suction, oxygen, and BVM; consider an antiemetic. Benzodiazepines are not mandatory and may depress respiration—reserve for severe emergence phenomena. Large unmonitored boluses risk oversedation. Thorough documentation (dose, route, time, response) supports continuity and legal/clinical requirements. Combine pharmacologic therapy with mechanical measures (splinting, wound care) and frequent reassessment. This disciplined approach delivers reliable analgesia with minimal risk in austere environments.

Danger area crossing with a casualty demands coordination: near-side element secures, litter team crosses under cover, far-side establishes security, then the rest bound across. Pre-briefed hand signals reduce radio chatter and confusion. Sprinting without coordination risks fratricide and loss of security. Random order undermines sectors of fire and accountability. Stopping mid-crossing increases exposure to enemy observation and fire. Integrate CCP/HLZ triggers and contingency routes; ensure the litter is pre-rigged with straps, and designate roles (lead, rear, flank security). This doctrinal approach balances survivability with movement efficiency in contested terrain.

Junctional hemorrhage cannot be controlled with a standard limb tourniquet. The lifesaving step is either applying a junctional tourniquet (if available) or aggressive hemostatic wound packing with sustained pressure. IV fluids alone do not stop bleeding and risk dilutional coagulopathy. Upright positioning worsens hemodynamics. This intervention, combined with hypothermia prevention, TXA, and rapid evacuation, prevents one of the deadliest preventable causes of battlefield death.

Casualty movement exposes teams to significant risk. Security provides overwatch, suppressive fire, and situational awareness, ensuring safe evacuation. Time savings alone cannot guarantee survivability. Security does not replace medics or serve only for HLZ identification. Integrating security with casualty movement drills ensures evacuation does not compromise mission effectiveness and force protection. This balance is essential for operational survivability.