A casualty goes down with a fragment wound high in the thigh. The rifleman beside him gets a limb tourniquet on and drags him to cover. The squad's Combat Lifesaver arrives, finds a sucking wound on the lateral chest, and seals it. The platoon medic takes over, sees the bleeding coming from the groin above the tourniquet, and reaches for a junctional device. Three people touched that casualty, and each one worked inside a different scope.
That is the point of TCCC's four role-based tiers. Each tier owns a defined skill set, and the skill a responder reaches for must match the tier they trained for.
DoD Instruction 1322.24, Medical Readiness Training, requires role-based TCCC training for service members [1]. The Joint Trauma System curriculum defines four roles: All Service Members (ASM, Tier 1), Combat Lifesaver (CLS, Tier 2), Combat Medic/Corpsman (CMC, Tier 3), and Combat Paramedic/Provider (CPP, Tier 4) [2,3]. The Tier 3 column in the skill-set matrix names the 68W combat medic, the Navy 8404 corpsman, and the Air Force 4N technician [3].
The clinical content comes from the TCCC Guidelines. The current edition is dated 1 May 2026 [4,5]. The skill-to-tier assignments come from the JTS document "TCCC Skill Sets by Responder Level" [2]. A version dated 22 April 2019 was published in a peer-reviewed journal [3], and JTS has revised the matrix since. When a unit lesson plan and that matrix disagree, the current Deployed Medicine release decides.
The tiers stack. Each one keeps every skill below it and adds its own.
ASM is the floor for everyone in uniform. The JTS ASM course teaches rapid casualty assessment, limb tourniquet application, hemostatic dressing and wound packing, pressure bandages, airway positioning maneuvers, and drags and carries [2]. Those skills treat the injuries that kill fastest when nobody acts.
CLS is a non-medical service member with extra training and a primary job that is not medicine. CLS adds three things that matter in the matrix:
The biggest 2026 change moves tourniquet work down to the nonmedical tiers. Every tier reassesses a tourniquet as soon as tactically feasible and no later than two hours after it goes on. ASM and CLS may now reposition a tourniquet and convert it to a hemostatic or pressure dressing inside that window. Before this change, reassessment and conversion started at CLS, and ASM did neither [6]. Shock remains a reason not to convert [6]. The window has a hard edge: after two hours, ASM and CLS do not attempt conversion unless directed by a Combat Medic/Corpsman, a Combat Paramedic/Provider, or other advanced medical personnel. Without that oversight, they keep the tourniquet on and keep monitoring [4,6]. The decision logic behind conversion is covered in Tourniquet Tactics: TCCC Decision-Making for Medics.
Tier 3 is the first tier whose primary duty is medical care. The skills it adds are the ones a nonmedical responder cannot do safely:
One correction belongs here. Extraglottic airways were removed from the TCCC guideline in January 2024 [4,10]. A lesson plan that still lists a supraglottic airway as a medic skill is teaching retired doctrine.
Tier 4 holds the procedures with the highest risk and the smallest margin. The responder-level skill list assigns simple finger thoracostomy and tube thoracostomy to CPP only [2]. Needle decompression remains the first answer to tension physiology at every tier from CLS up.
CPP is also the tier that gives direction. The 2026 tourniquet rule names CPP and CMC as the people who authorize a lower-tier conversion after two hours [4]. When evacuation stalls for hours or days, the work shifts toward prolonged care, covered in PFC Fundamentals: Managing Casualties Beyond the Golden Hour.
MARCH does not change between tiers. What changes is how far down each step a responder can go. This table lists only skills confirmed in the sources above. A blank means no added skill was confirmed for that tier, not that the tier skips the step.
| Step | ASM | CLS adds | CMC adds | CPP adds |
|---|---|---|---|---|
| Massive hemorrhage | Limb tourniquet, wound packing, pressure bandage; reassess, reposition, and convert a tourniquet within 2 h | Junctional tourniquet; conversion after 2 h; directs ASM/CLS conversion after 2 h | Directs ASM/CLS conversion after 2 h | |
| Airway | Positioning, recovery position | Surgical cricothyroidotomy | ||
| Respiration | Vented chest seal; needle decompression; NPA as an adjunct to BVM ventilation | Finger and tube thoracostomy | ||
| Circulation | IO access | |||
| Pain (PAWS) | Ketamine or esketamine |
The blanks are the training question. If your unit teaches a skill in a blank cell, find the authority for it before the next class.
A tier is earned once and lost slowly. In a randomized trial of 465 laypeople, 88% applied a tourniquet correctly right after a one-hour course. At 3 to 9 months, 54.5% of the 303 retested could still do it [8]. The medic tier is not immune. In a pilot study of nine National Guard combat medics due for annual recertification, 44.4% placed a tourniquet successfully and 22.2% packed a wound successfully; experience did not predict success [9]. That sample is small, and the result is still a warning.
Both studies point the same way: one training block a year does not hold a skill. A free scenario is one way to rehearse the decision between classes.
Yes. Needle chest decompression sits at CLS, CMC, and CPP [2]. The needle size and sites are in the CLS section above.
No. The junctional tourniquet skill cards sit in the Combat Medic/Corpsman and Combat Paramedic/Provider courses [2]. A Combat Lifesaver controls a junctional wound with hemostatic packing and direct pressure until a medic arrives.
DoD Instruction 1322.24 requires role-based TCCC training [1]. The Joint Trauma System curriculum defines what each of the four roles must do, and the CoTCCC guidelines set the clinical content [2,4]. Recertification intervals come from that instruction and service policy, so check your service's current guidance.
I am the final authority for training program requirements and curriculum at our training site, and the tier is where lesson plans drift. Nobody writes a bad plan on purpose. A skill migrates down one tier because an instructor was comfortable teaching it, or up one tier because nobody had the equipment. Five years later the drift is the curriculum. This article gets the important thing right: the tiers are not a ladder of prestige. They are a contract. The ASM soldier owns the bleed and the airway position. The Lifesaver owns the chest. The medic owns the decisions a nonmedical responder cannot make safely. Each tier works because the one above it shows up. Break that contract in either direction and the casualty pays for it, whether a Lifesaver reaches for a device nobody trained him on or a medic waits for a skill the Lifesaver was never taught.
That being said, the matrix tells you what each tier may do, and it says nothing about what each tier can still do. Those are different questions, and the second one is the one that matters at the point of injury. The honest answer is that I trust a tier assignment exactly as far as the last time that soldier did the skill under a watching eye. The 2026 tourniquet change makes this sharper. It hands conversion to the Lifesaver for the first two hours and takes it back after that. A Lifesaver who must wait for direction after two hours needs a medic who knows that rule and a radio that works. If either is missing, the rule protects the limb on paper and abandons it on the ground. Plan the communication before you plan the class.
If you are the medic on the ground, learn the tier of every soldier in your formation before you need them. Know who is CLS trained, when they last trained, and which of them has actually put a needle in a chest trainer this year. Make sure every Lifesaver knows how to reach you inside the two-hour tourniquet window, and rehearse that call as a drill rather than a briefing slide. If you are a medical officer, audit one lesson plan this month against the current skill-set matrix, line by line, and strike every skill sitting in the wrong tier. Then check that your evaluators score each skill at the tier the soldier holds, not the tier the instructor holds. A soldier trained in the wrong tier will do the wrong thing with total confidence.
— Chester Shermer, MD, FACEP | Emergency Medicine, 25+ Years Clinical Experience | State Surgeon
If you're a combat medic, corpsman, flight medic, or military medical officer (or any clinician treating patients daily) trying to understand how AI will actually impact your clinical practice — not just the hype — I put together a free practical guide. You can download the AI in EM Survival Guide here.
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Relevant Reading on Global MedOps Command:
How to Avoid Becoming an AI Casualty — Dr. Shermer's guide to navigating AI tools in clinical and operational settings without compromising judgment or patient outcomes.
Emergency Department Efficiency Playbook — Practical systems for throughput, triage optimization, and operational efficiency.
Read more from Dr. Shermer on Medium
Connect with Dr. Shermer: LinkedIn — Chester "Chet" Shermer, MD, FACEP.
Related simulation training: EMS-MedSim · Books by Dr. Shermer