Royal Army College

Lesson Overview

First aid keeps a casualty alive; it rarely makes them well. The wound still needs a surgeon, the illness a hospital. So almost every casualty must be moved, and almost every casualty must be handed over. This lesson covers both: when to move a casualty and when not to, how it is done safely at a basic level, and the larger system the casualty travels through, ending with handover to the civilian medical services.

This is the knowledge layer. The hands-on skills (lifts, drags, carries, immobilisation) are taught and certified in person, under qualified instruction, and you do only what you are trained and currently authorised to do. You are a trained first responder, not a medic: you keep the casualty alive and keep help coming, and you leave advanced handling and equipment to those certified for it. The clinical detail here is confirmed by the College's medical staff and follows current internationally recognised practice, including the humanitarian first-aid method and the United Nations medical and evacuation framework. It builds on Lesson 02 (the systematic sequence and continuous reassessment) and Lesson 05 (the secondary survey, the casualty's history, and monitoring), and the handover you build feeds the casualty report of the Signals and Field Communication course. By the end you will be able to judge when to move a casualty and when not to, keep the head and spine in line in principle, choose and describe the basic drags and carries for one and two people, improvise a stretcher and lift it as a team, package a casualty for the move, give a clear structured handover, request evacuation, and explain how the Army's chain of care and the levels of medical care fit together.

Key Terms

CASEVAC: casualty evacuation, moving a casualty from the point of injury to the nearest suitable medical facility by whatever transport is available.
MEDEVAC: medical evacuation, the further, planned movement of a casualty between medical facilities, on medical advice.
Emergency move: a fast move made under immediate danger, accepting roughness to get the casualty out of harm; the drags belong here.
Casualty report: the structured request for help to an injured person, giving who and where they are, their condition and number, and what is needed; the format is taught in full in the Signals and Field Communication course.
Handover: the disciplined, structured transfer of a casualty and everything known about them from one carer to the next, so nothing learned is lost.
Packaging: preparing a casualty to travel, kept warm, secured against the movement, with their treatments held in place and a way to keep watching them.
Spinal precautions: keeping the head and spine in line and steadying them by hand so a possible spinal injury is not made worse by movement.
Levels of care: the layered system of medical facilities, from Level 1 (a doctor and basic stabilisation) up to Level 4 (definitive, specialist care), through which a casualty moves toward recovery.

When not to move, and when you must

The safe rule: a casualty is left where they are while you treat them, unless leaving them there is more dangerous than moving them. Unnecessary movement worsens injuries. A spine may be damaged, a fracture displaced, bleeding restarted. Movement is a decision, not a reflex. A still casualty who is stable, breathing, and being watched is, more often than people expect, best left exactly where they lie, with you protecting them in place, until help reaches you or a clear reason to move appears. This holds doubly where a spinal injury is possible: a casualty who is not in danger and is being monitored is not improved by being dragged about, and may be greatly harmed by it.

So before you touch a casualty to move them, settle one question: is there a reason that outweighs the harm of moving? Only three do.

   MOVE only when one of these is true:

   1. DANGER where they lie
      fire, smoke, collapsing structure, rising water,
      traffic, live electricity, continuing hostile fire.
      The danger will reach them faster than help will.

   2. You cannot give LIFE-SAVING care where they are
      you cannot open or protect the airway in the position
      they are in, or you cannot reach a bleed to control it,
      and a small, careful change of position is the treatment.

   3. You must EVACUATE
      the casualty has to be carried to a collection point or
      to transport, because care beyond first aid is what they
      need and it is somewhere else.

   If none of these is true: LEAVE IN PLACE, PROTECT, MONITOR, KEEP HELP COMING.

The judgement weighs two risks: the harm of the danger you are in, and the harm of the move itself. Where there is a real risk of spinal injury (from a fall, a blast, a vehicle accident, a heavy blow to the head or back), avoid moving the casualty if you safely can; and where you must, steady the head and neck and keep the body in line. But danger to life always comes first. A casualty in a burning vehicle is moved, spine or no spine, because a perfectly protected spine is no use to a casualty who has burned. Life before limb, and a possible injury you cannot see never outranks a certain danger you can.

The spinal caution: keeping the head and spine in line

When you suspect a spinal injury, the principle behind every careful move is simple to state and harder to do: keep the head, neck, and back in one straight line, and do not let them twist, bend, or sag. The spinal cord runs inside the spine like a wire inside a flexible tube; the bones can be cracked without the cord being cut, and a clumsy movement is what turns a cracked bone into a severed cord, a recoverable casualty into a paralysed one. The first responder's task, in principle, is to stop the movement that does the damage.

You suspect a spinal injury from the mechanism more than from anything the casualty says: a fall from a height, a vehicle accident, a blast, a heavy object striking the head or back, a dive into shallow water, or any unconscious casualty whose history you do not know. Pain in the neck or back, tingling, numbness, limb weakness, or a casualty who instinctively will not move all add to the suspicion. Their absence does not clear it, because a frightened casualty full of adrenaline may feel little at first.

Where a spinal injury is suspected and the casualty must be steadied or moved, the principle is manual in-line stabilisation: a responder takes the head gently but firmly in both hands and holds it in line with the body, neither pulling nor twisting, simply preventing movement, while others do the rest. The head is brought into line, not forced; if moving it that far meets firm resistance or sharply increases pain, it is held where it is. When the casualty must be turned or lifted, everyone moves on one command so the whole body travels as a single rigid unit, the head kept in line throughout. None of this replaces the proper immobilisation a medic brings; it is what a first responder does, by hand, in the minutes before that arrives, and it is practised and certified in person because the feel of it cannot be learned from a page.

Emergency moves one person can do: the drags and carries

How a casualty is moved depends on the danger, the distance, the ground, and the help and equipment you have. The detail and the practice belong to your certified training; the knowledge here is the shape of it and the discipline behind it. The fastest moves, the drags, are for escaping immediate danger over a short distance, alone. They are rough by nature, so they buy survival, not comfort, and are not for moving a casualty any real distance.

The clothing drag. Grasp the casualty's clothing at the shoulders, behind the collar or under the upper back, support the head against your forearms as best you can, and drag them along the ground in the line of the body, feet trailing. It suits a casualty you must move now, and keeps the head and spine roughly in line because you pull along the body's length, not across it. Good on hard, smooth ground and brutal over rocks; watch the clothing does not ride up and choke the casualty.
The shoulder or collar drag. A variation for when the back is the best hold: take the casualty under the armpits from behind, support their head against your forearms, and walk backwards. It gives more control of the head than a low clothing grab and suits dragging a casualty through a doorway or out of a vehicle. Keep your hips low and let your legs do the work.
The cradle. For a light casualty a short distance, gather them across your arms, one arm under the back and one under the knees, held against your chest. It is the gentlest one-person carry and lets you watch the casualty's face, but it tires you quickly and works only for a casualty much lighter than you, a very short way. It is poor over broken ground, because both arms are committed and you cannot save yourself if you stumble.
The pack-strap carry. To move a casualty further alone, bring them onto your back: their weight high across your shoulders and upper back, their arms over your shoulders and down your chest, held by your hands, so the load sits on your skeleton, not your arms. Carried high and close, a surprisingly heavy casualty can be moved a useful distance, and you keep one hand partly free. Getting the casualty up onto you is the hard part and the part most worth practising. It is unsuitable for a suspected spinal injury, because it bends and twists the back.

Two principles run through all of it. Lift safely: back straight, the work done by your legs, feet apart and close to the casualty, so you do not become a second casualty. A wrenched back at the point of injury removes the one person the casualty has. And never carry further than you must: get the casualty clear of the danger, then set them down in cover and reassess, rather than struggling on to exhaustion and dropping them.

Two-person methods: sharing the load

Two carers are far better than one for any distance: the load is halved, the casualty is steadier, and one person can mind the head and airway while the other minds the legs and the route. Two-person methods are the workhorses of moving a casualty between the danger area and the point where a stretcher or transport takes over.

The fore-and-aft carry. One carer takes the casualty under the arms from behind (the head end), the other stands between the casualty's legs facing forward and takes them under the knees (the foot end). Lifting together on command, the two walk the casualty in the line of the body. It is quick, needs no equipment, lets the head-end carer protect the airway, and passes through narrow gaps a side-by-side seat will not fit. Not for a suspected spinal injury, because the body sags in the middle.
The two-handed seat. The carers face each other on either side of the casualty and link a low, locked grip of wrists and arms under the casualty's thighs, with their free arms behind the casualty's back to support it. The casualty, if able, puts an arm around each carer's shoulders. They lift together and walk side by side. It suits a conscious casualty carried a fair distance over open ground; the back support makes it steadier than the four-handed seat.
The four-handed seat. Each carer grips their own wrists and the other carer's to build a square "seat" of four forearms for the casualty to sit on. It needs a conscious casualty who can sit up and hold on, because there is no back support, but it is simple, strong, and quick to form. It suits a walking-wounded casualty who cannot walk, over open ground, between two fit carers.

   ONE PERSON                              TWO PERSON

   clothing / shoulder drag  -- danger,    fore-and-aft carry  -- distance, narrow
     short, fast, head in line               gaps, head watched at the front
   cradle  -- very light, very short       two-handed seat  -- conscious casualty,
   pack-strap carry  -- further, alone,      back supported, fair distance
     casualty up on your back              four-handed seat -- conscious casualty
                                             who can hold on, quick to form

   NONE of these is for a suspected spinal injury except as an emergency move
   from danger, head kept in line, everyone moving on one command.

Whichever method, the rule holds as for one person: lift with the legs, keep the casualty close, and move on a clear, counted command so both carers rise and step together. A casualty dropped in a hurried, uncoordinated carry can be hurt worse than by the original wound.

Improvising a stretcher, and lifting as a team

For any real distance, and above all for a casualty who must be kept still, a stretcher beats arms. It spreads the load, keeps the casualty in line, frees the carers to share the weight evenly, and lets a suspected spinal injury be moved with the body supported along its length. You will rarely have a purpose-made stretcher to hand, so the skill is to make one safely from what you carry.

Poles through jackets. Take two strong, straight poles a little longer than the casualty. Fasten two or three sturdy jackets or smocks shut, then thread a pole through the sleeves of each side, inside the body of each garment, so the garments form the bed and the sleeves grip the poles. Test it with a fit person's weight, taken slowly, before trusting a casualty to it: a stretcher that fails under a casualty is worse than no stretcher.
The blanket roll. Lay a strong blanket or tarpaulin flat, place the casualty along the middle, and roll the long edges tightly inward on each side until the rolls form firm handholds along the length. With enough carers gripping the rolls close to the body, the casualty can be lifted and carried level. It needs no poles but needs hands, four to six carers, and works best over a short distance.

Improvised stretchers are strong enough only if they are tested first and gripped close to the casualty; a long span of unsupported fabric or a weak pole will fail. Whatever the stretcher, the lift and the carry are done as a team under one clear voice. One person, by convention at the head, takes command, because the head-end carer sees the casualty's face, controls the airway and, where there is a spinal concern, holds the head in line. That commander gives the orders and everyone else obeys them exactly.

   LIFTING AS A TEAM (one voice, at the head)

   "Prepare to lift"   carers take their holds, feet apart, backs straight,
                       grip checked, the casualty's head supported
   "Lift"              all rise together, legs doing the work, casualty level
   "Prepare to move"   carers settle the load, ready to step off together
   "Move"              all step off on the same foot, slow and even
   "Halt" / "Lower"    all stop, then lower together on the command

   The casualty travels level and in line. Nobody moves on their own.

The same discipline governs getting a casualty onto the stretcher: with a spinal concern, the casualty is log-rolled or lifted as one rigid unit, head kept in line, on the commander's count, so no part of the spine twists or sags while the stretcher is slid beneath. Set the stretcher down to rest the carers rather than risk a drop; change carers in turn, never all at once. All of this is practised and certified in person, because timing and grip are things the hands must learn.

Packaging the casualty for the move

A casualty made ready to travel is packaged: prepared so the move itself does not undo your treatment or harm them further. A casualty is more fragile in motion than at rest, colder, jolted, harder to watch, so the few minutes spent packaging before you set off are repaid in a casualty who arrives in the state you treated, not worse.

Warm. Movement and shock both rob a casualty of heat, and cold makes bleeding worse and recovery harder, so insulate the casualty from the ground and cover them, including the head, before and during the move. Lesson 06 sets out why a cold casualty is a worse casualty; on a stretcher in the wind, the danger is greater still.
Secured. A casualty who can slide, roll, or fall from a stretcher is in danger from the carry itself. Secure them across the chest, hips, and legs, firmly but not so tightly that breathing is restricted, the arms held safely and not left to dangle. On uneven ground or a slope this is what keeps the casualty on the stretcher.
Treatments held. Check before you lift that nothing you have done will fail in transit: dressings firm and not slipping, any tourniquet visible and its time still recorded, the airway position maintained, an injured limb supported so it does not move. Anything that can be dislodged by a jolt, fix before the jolt comes.
Monitored. Package the casualty so you can keep watching: the face visible, breathing and colour where you can see them, and a carer charged with watching, not just lifting. This connects directly to Lesson 05: go on noting level of consciousness, breathing, pulse, and skin, on the move and at every halt, because the trend warns you they are getting worse, and a casualty can deteriorate silently under a blanket. And as Lesson 02 taught, reassess after any move; moving a casualty is exactly when a tourniquet slips or breathing falters, so the first thing you do after setting them down is run the sequence again.

A packaged casualty is one you can carry, keep warm, keep on the stretcher, and keep watching, all at once: that is the standard to reach before the command to lift.

The handover: a disciplined, structured report

A casualty almost always passes from your hands to another's, and the quality of that handover decides whether care continues smoothly or falters. Everything you know about the casualty (the mechanism, the injuries, the signs and how they changed, the treatment and its timings) lives only in your head and your notes until you hand it over. If the handover is muddled, that knowledge is lost and the next carer starts half-blind. So the handover is treated as a drill, not a conversation: short, ordered, factual, delivered the same way every time. A calm, plain report carries more than an excited one.

The notes you built in the secondary survey and monitoring of Lesson 05 are the raw material; the handover is how you deliver them. A fixed order protects against the way a stressed mind drops the awkward fact, runs words together, and forgets what it has not been prompted for. Give it in this order:

   THE HANDOVER (give it in this fixed order, calmly and plainly)

   IDENTITY and AGE      who the casualty is, and roughly how old
   TIME and MECHANISM    when it happened, and what caused it and with what force
                         (the fall, the blast, the impact, the burn)
   INJURIES FOUND        the injuries you found, head to toe, the worst first
   SIGNS and VITAL SIGNS level of consciousness (alert / voice / pain / none),
                         breathing, pulse, skin, and HOW THEY HAVE CHANGED
   TREATMENT GIVEN       what you did and WHEN, above all the time any
                         tourniquet went on, then dressings, position, warming

   Hand over your written notes with the words. End by stating what you
   think the casualty needs most, clearly labelled as your judgement.

A handover in this shape takes only a short while and carries only what matters. Read from your notes if you can; have a second person check; give times as clock times, not "a while ago". When the casualty also needs evacuation, the same facts feed the casualty report, the structured request for help taught in full in the Signals and Field Communication course, which gives the receiver where the casualty is, the number and priority of casualties, whether they are stretcher or walking, and how the pickup point is marked and whether it is safe, so help can launch without asking further questions. If time is short, the first few lines are enough to get help moving; the detail follows. The handover and the casualty report are two faces of the same discipline: say everything that matters, in a fixed order, so nothing learned is lost.

This handover is given the same way whoever receives it, and it will often be received not by a uniformed medic but by a civilian paramedic. The standard of accuracy is exactly the same; what changes is the language. Civilian providers will not know military jargon, so speak plainly, give times, answer questions directly, and hand over your written notes as you would to a medic. Once the casualty enters the civilian medical system, those clinicians lead the care; the Army escorts, protects, documents, and supports, but does not override civilian clinical judgement. The Army keeps its procedures deliberately compatible with civilian practice, and rehearses with the civilian ambulance service, precisely so this handover goes smoothly when it matters. Care is owed to everyone by need alone, and a clean handover across that boundary is part of giving it.

The chain of care and casualty evacuation

A casualty's journey runs along a chain of care from the point of injury to definitive treatment, and the early links are timed. The first link is you: buddy aid given by whoever is there, usually a soldier and not a medic, in the first minutes. From there the casualty passes through medical care of rising capability until they reach a hospital. International practice, which the Army follows, uses a simple planning timeline summarised as 10-1-2: life-saving first aid within the first 10 minutes; advanced care and stabilisation within about one hour; and damage-control surgery, where needed, within about two hours. These targets explain why the responder at the point of injury matters so much: the first ten minutes belong to first aid, not the surgeon, and they are usually the most decisive ten minutes the casualty will have.

Two terms describe the movement. CASEVAC is the first leg, getting the casualty from the point of injury to the nearest suitable facility by whatever transport is fastest, and it takes priority over almost everything except countering an immediate threat to life. MEDEVAC is the further, planned movement between facilities, made on medical advice according to how urgent and specialised the need is. Ownership of the evacuation sits at the highest level that can command it, but the execution happens at the lowest, with the soldiers on the ground, which is why your part (sound first aid, a casualty packaged ready to move, and a clear handover) is the foundation the rest is built on.

The levels of medical care

Behind the chain of care stands a layered system of medical facilities, the levels of care, each able to do more than the last.

Level 1 is the first stationary facility with a doctor: primary care, immediate life-saving and resuscitation, casualty collection, limited sorting, stabilisation, and preparation for the next stage.
Level 2 adds surgery, including damage-control surgery, post-operative and intensive care, inpatient beds, and basic imaging and laboratory work.
Level 3 is a fuller hospital, with specialist surgical and diagnostic services and greater capacity for the seriously ill.
Level 4 is the highest, definitive and specialist care, including severe burns and long rehabilitation, usually away from the immediate operational area.

The casualty moves up these levels only as far as their condition requires. The point of injury, where the soldier and the buddy-aid kit are, sits before Level 1; it is the start of the chain, and often the most decisive part.

The chain of care, from the point of injury:

flowchart LR
    POI["Point of injury<br/>buddy aid, first 10 minutes"] --> CAS["CASEVAC<br/>fastest move to care"]
    CAS --> L1["Level 1<br/>doctor: resuscitate, stabilise<br/>(within about 1 hour)"]
    L1 --> L2["Level 2<br/>damage-control surgery<br/>(within about 2 hours)"]
    L2 --> L3["Level 3<br/>fuller hospital"]
    L3 --> L4["Level 4<br/>definitive, specialist care"]

Further planned moves between facilities are MEDEVAC, made on medical advice.

How the Army organises medical support, and handover to civil services

The Principality is small, and the Royal Kaharagian Army cannot maintain a deep chain of military hospitals of the kind a large nation operates. As a small humanitarian home-defence force, its plan rests on early stabilisation, rapid handover, and close cooperation with the civilian medical services. At the point of injury, the soldier gives buddy aid; a section medic, where present, adds what is within their scope. A casualty collection point, marked on patrol orders, is the safer place where casualties are gathered, re-sorted, and prepared for evacuation. Beyond it, the higher levels of care are provided by the Army's own medical staff, by partner facilities on combined operations, and, for definitive care, by the civilian hospital system.

So, often within the first hour, the casualty crosses an organisational boundary, and the handover is received by a civilian paramedic, not a uniformed medic, as the handover section above sets out. The first responder's part does not end at that boundary: you escort, protect, keep documenting, and support the civilian clinicians who now lead. Care is owed to everyone by need alone, soldier and civilian, the lightly and the gravely hurt, and a clean handover across that boundary is part of giving that care in full.

In Practice: From a Roadside to the Hospital Door

A section is returning along a rural road one cold evening when a civilian car ahead leaves the road and strikes a tree. One occupant is badly hurt: slumped, breathing, bleeding from a leg, not moving their neck. The section commander takes charge and the drill begins.

The car is not on fire and the road can be made safe by posting a soldier to warn traffic, so the casualty is left in place rather than dragged out: the mechanism, a hard impact, makes a spinal injury likely, and no danger outweighs the harm of moving. One soldier takes the head in both hands and holds it in line while the others do the things that save life from Lessons 02 to 05: the bleeding leg controlled, the airway watched in the position the casualty sits, the casualty kept still, insulated from the cold, and covered. A soldier runs the systematic sequence and begins noting the level of consciousness, breathing, pulse, and skin, with the time against each.

The casualty report goes out at once, the first lines first, giving the location, that there is one stretcher casualty, urgent, at a roadside the section will mark and make safe. While they wait, the casualty is packaged: lifted clear onto an improvised stretcher of poles through smocks, tested first with a soldier's weight, by a log-roll as one rigid unit on the commander's count, head kept in line, then secured across the chest, hips, and legs, kept warm, dressings checked, the head-end carer watching the face. The lift is on one voice, "prepare to lift, lift, prepare to move, move", and the casualty travels level. After the move the sequence is run again, because moving a casualty is when things slip.

When the civilian ambulance arrives, the soldier who kept the notes gives a short, plain handover in the fixed order: who the casualty is and roughly their age; the time and mechanism, a vehicle striking a tree at speed; the injuries found, head to toe, worst first; the signs and how they have changed, the pulse climbing over the last fifteen minutes; and the treatment given, with times. The written notes go over with the words, no jargon, just facts and times. From there the casualty travels up the chain of care, through the levels of medical care, to definitive treatment, now in civilian hands; the section escorts and supports but does not override. The section did the first and most decisive part, kept help coming, and handed it on cleanly. That is the chain of care working as it should.

Check Your Understanding

What is the safe rule about moving a casualty, and what are the only reasons that justify moving one anyway? How does the risk of spinal injury fit into that judgement, and what does keeping the head and spine in line mean in principle?
Name two one-person methods and two two-person methods of moving a casualty, and say what each one suits. Why is none of them used for a suspected spinal injury except as an emergency move from danger, and what does "lift with your legs" protect against?
Set out the order of a good handover, identity and age through to treatment given, and explain why accuracy and clear times matter more than dramatic language. How does this handover feed the casualty report of the Signals and Field Communication course, and where do the point of injury and buddy aid sit in the chain of care and the levels of medical care?

Reflection (write a short paragraph): A casualty you have treated and packaged will often be handed to a civilian paramedic rather than a military medic, within the first hour, across an organisational boundary. Why does this make a disciplined, fixed-order handover, plain speech, and clear times so important, and what does it tell you about how a small humanitarian home-defence force connects its care to the civilian system it serves and to the principle that care is owed to everyone by need alone?

Summary

Leave a casualty where they are while you treat them unless there is danger where they lie, you cannot give life-saving care in place, or you must evacuate; movement is a decision, not a reflex, and danger to life comes before protecting a possible spinal injury.
Where a spinal injury is suspected, keep the head, neck, and back in one line, steady the head by hand, and move the whole body as a single unit on one command; this and all lifts and carries are practised and certified in person.
Emergency moves one person can do are the clothing and shoulder or collar drags, the cradle, and the pack-strap carry; two-person methods are the fore-and-aft carry and the two-handed and four-handed seats, each suited to a different casualty and distance; lift with your legs so you do not become a second casualty.
Improvise a stretcher from poles through jackets or a blanket roll, test it before trusting a casualty to it, and lift and carry as a team under one clear voice; package the casualty warm, secured, with treatments held and a carer watching, and reassess after every move.
Hand over as a drill in a fixed order, identity and age, time and mechanism, injuries found, signs and vital signs and how they changed, treatment given and its times, handing over your written notes; the same facts feed the casualty report of the Signals and Field Communication course.
The chain of care is timed (the 10-1-2 idea: first aid in 10 minutes, advanced care in an hour, surgery in two), with CASEVAC the first leg and MEDEVAC the planned moves between the levels of care (Level 1 to Level 4); the small humanitarian Army relies on early stabilisation, rapid handover, and cooperation with civilian services, so speak plainly, give times, and let civilian clinicians lead once the casualty is in their care. You are a first responder, not a medic: keep the casualty alive, keep help coming, and hand on cleanly.

Moving the Casualty and the Chain of Care