From its humble beginnings as a Naval Special Warfare biomedical research effort to a joint US Special Operations Command (USSOCOM) and Uniformed Services University of Health Sciences (USUHS) research project, TCCC has led a systematic review of all aspects of battlefield trauma care into a set of guidelines designed to combine good medicine with good small-unit tactics. Today, and after nearly two decades of combat operations, the Committee on Tactical Combat Casualty Care and the Joint Trauma System continuously reviews casualty data, best practices, lessons learned, research projects and medical literature to produce a set of evidence-based, best-practice prehospital trauma care guidelines customized for use on the battlefield.
The overall objective of TCCC is to teach service members how to effectively treat combat casualties while preventing additional casualties and completing the mission at hand. The three phases of TCCC include care under fire, tactical field care and tactical evacuation care.
* Care Under Fire (CUF) outlines strategies using limited medical equipment to render care at the point of injury while the first responder and the casualty are still under hostile fire.
* Tactical Field Care (TFC) provides casualty care guidelines once the first responder and the injured combatant are no longer under hostile fire.
* The Tactical Evacuation Care (TACEVAC) phase begins once the casualty has been transferred to a transport aircraft or vehicle. During this phase additional medical personnel and equipment may be available to provide augmented casualty care.
TCCC has been shown to be very effective in saving lives on the battlefield. For this reason in 2005, the United States Special Operations Command required TCCC training for all deploying combatants and not just medical personnel. The conflicts in Iraq and Afghanistan have enabled the US Military to make numerous advances in battlefield care. This module will explain what TCCC is and why you need to learn about it. Our military presently has the best casualty treatment and evacuation system in history. TCCC is what will keep you alive long enough to benefit from it.
For U.S. military service members wounded on the battlefield, the most critical phase of care is the period from the time they are injured until they arrive at a medical treatment facility (MTF) capable of providing the surgical care they need. If a casualty survives long enough to reach the care of a combat trauma surgeon, the likelihood is very high that he or she will survive. Almost 90% of our service men and women who die from combat wounds do so before they arrive at an MTF. This fact highlights the importance of the battlefield trauma care provided by combat medics, corpsmen, and pararescuemen (PJs) as well as nonmedical unit members in improving the survival of our country’s combat wounded.
Prehospital trauma care on the battlefield varies in many respects from prehospital trauma care as practiced in the civilian sector. The types and severity of the injuries are different from those encountered in civilian settings, and combat medical personnel face multiple additional challenges in caring for their wounded teammates in tactical settings. They must provide care while under hostile fire, often working in the dark, with multiple casualties and limited equipment. In addition, they must often contend with prolonged evacuation times as well as the need for tactical maneuvers superimposed on their efforts to render care. Treatment guidelines developed for the civilian setting do not necessarily translate well to the battlefield. Preventable deaths and unnecessary additional casualties may result if the tactical environment is not considered when developing battlefield trauma care strategies
These considerations notwithstanding, at the onset of hostilities in Afghanistan, most U.S. combat medical personnel were being trained using the following civilian-based principles of trauma care:1
Rendering care with no structured consideration of the evolving tactical situation
No use of tourniquets to control extremity hemorrhage
Managing external hemorrhage with prolonged direct pressure, precluding the medic from attending to other injuries or rendering care to other casualties
No use of hemostatic dressings
Two large-bore intravenous lines (IVs) started on all patients with significant trauma
Treatment of hypovolemic shock with large-volume crystalloid fluid resuscitation
No special considerations for traumatic brain injury (TBI) with respect to avoiding hypotension or hypoxia
Management of the airway in facial trauma or unconscious casualties with endotracheal intubation
No specific techniques or equipment to prevent hypothermia and secondary coagulopathy in combat casualties
Management of pain in combat casualties with intramuscular (IM) morphine—a battlefield analgesic that dates to the Civil War
No intraosseous (IO) access
No prehospital electronic monitoring
No effective nonparenteral analgesic medications
No prehospital antibiotics
No delineation of which casualties might benefit most from supplemental oxygen during tactical evacuation
Spinal precautions applied broadly to casualties with significant trauma, without consideration of tactical concerns or mechanism of injury
Guidelines and Key Points
Prehospital trauma care in tactical settings is very different from civilian settings. Tactical and environmental factors have a profound impact on trauma care rendered on the battlefield. Good medicine can be bad tactics.
Good first responder care is critical. Up to 28% of combat deaths today are potentially preventable, so good battlefield care is paramount in avoiding preventable deaths. Improvements in how we approach the combat casualty have resulted in significantly lower death rates in combat. TCCC is different from civilian trauma care training you may have received in the past, but TCCC will give you the tools you need!
The Three Phases of Care in TCCC are:
Care Under Fire
Care Under Fire is the very limited care that can be provided while the casualty and the provider are under effective enemy fire.
Tactical Field Care
Tactical Field Care is performed on the battlefield, but not under effective enemy fire.
TACEVAC Care
Tactical Evacuation Care is rendered during transport off the battlefield on the way to more definitive care
Tourniquets Reconsidered and the Need for TCCC
Extremity hemorrhage had been reported to be a leading cause of preventable death on the battlefield during the Vietnam conflict.3,6 Despite this fact, in 1992, U.S. military combat medics, corpsmen, and PJs were not being taught to use a readily available and highly effective treatment for extremity bleeding—a tourniquet.7-9 This realization led to a systematic review of all aspects of battlefield trauma care. This project was conducted from 1993 to 1996 as a joint effort of Special Operations medical personnel and the Uniformed Services University. This 4-year research effort culminated with the publication of the original TCCC paper in 1996.5,8,9
The Committee on Tactical Combat Casualty Care
The Committee on Tactical Combat Casualty Care and the TCCC Working Group
The need for periodic updates to the TCCC Guidelines was recognized early in the development of TCCC. The original TCCC paper recommended that the TCCC Guidelines be updated as needed by a DoD-sponsored committee established for this purpose.5 This concept was endorsed by the U.S. Special Operations Command (USSOCOM), and the Committee on Tactical Combat Casualty Care (CoTCCC) was subsequently funded in 2001 as a USSOCOM Biomedical Research Program. The command chosen to execute this project, the Naval Operational Medicine Institute, subsequently conducted the necessary coordination with Navy medicine leaders to ensure that there would be long-term support of this effort. BUMED programmed for financial and personnel support of the CoTCCC beginning in fiscal year 2004. In fiscal years 2007 through 2009, the Office of the Surgeon General of the Army, the U.S. Army Institute of Surgical Research, and the Defense Health Board (DHB) also provided substantial support for the CoTCCC.
CoTCCC Membership
Because the goal of TCCC is to provide the best possible medical care consistent with good small-unit tactics, it is essential that the membership of the CoTCCC include combat medical personnel as well as physicians. It is also critical to have tri-service representation to ensure that differences in doctrine and experience between the Army, Navy, and Air Force medical departments are identified and best practices from each are incorporated into TCCC. The combat medics selected include Navy SEAL corpsmen, Navy corpsmen assigned to Marine units, Ranger medics, Special Forces 18-D medics, Air Force pararescuemen, Air Force aviation medics, and Coast Guard health specialists. Physician membership includes representatives from the trauma surgery, emergency medicine, critical care, and operational medicine communities. Physician assistants, medical planners
CoTCCC Alignment
In 2007, due to the increasing visibility of TCCC in the Global War on Terrorism (GWOT), the Navy Medical Support Command proposed that the CoTCCC be moved to a more senior joint command. This proposal was briefed to the offices of the Assistant Secretary of Defense for Health Affairs and the Surgeon for the Joint Chiefs of Staff.
In March 2008, the CoTCCC was relocated to function as a working group of the Trauma and Injury Subcommittee of the Defense Health Board (DHB). The DHB is chartered to provide independent advice and recommendations to the Secretary of Defense through the Under Secretary of Defense for Personnel and Readiness and the Assistant Secretary of Defense for Health Affairs on medical issues, including the care of U.S. service members wounded in combat operations.
Later, on 21 February 2013, by Direction of the Acting Under Secretary of Defense for Personnel and Readiness, the CoTCCC was moved once more, this time to the Joint Trauma System (JTS) to have it co-located with the DoD’s combat trauma management system. In 2017, Congress made the JTS the DoD’s lead agency for trauma, and the CoTCCC is the prehospital component of the JTS.
TCCC Guideline Updates
Since 2001, and throughout these organizational changes, the CoTCCC has continued to monitor developments in prehospital trauma care. The TCCC Guidelines are updated based on: (1) ongoing review of the published civilian and military prehospital trauma literature; (2) ongoing interaction with military combat casualty care research laboratories; (3) direct input from experienced combat corpsmen, medics, and PJs; (4) input from the service Medical Lessons Learned Centers; (5) case reports discussed at the weekly Joint Theater Trauma System (JTTS)process improvement video teleconferences; (6) observations on the causes of death in combat fatalities gleaned from JTS-Armed Forces Medical Examiner System (AFMES) conferences; and (7) expert opinion from both military and civilian trauma experts.
Each change to the TCCC Guidelines is now supported by a change paper published in the Journal of Special Operations Medicine. Guideline changes are also included in revisions of the PHTLS textbook.21,22
As the use of TCCC spread from the U.S. military to other agencies within the federal government, allied nations, and the civilian sector, it became important to include representatives from these groups in the TCCC update process, both to secure the benefit of their input and to facilitate communication between them and the CoTCCC. Accordingly, the CoTCCC began to invite liaison members from these groups to participate in its combat trauma care performance improvement process. The CoTCCC voting members and CoTCCC liaison members collectively comprise the TCCC Working Group, and it is through the untiring efforts of this group that the TCCC Guidelines and other TCCC knowledge products have remained state of the art through 16 years of conflict.8,21
Although the TCCC Guidelines are best-practice trauma care guidelines customized for use on the battlefield, they are only guidelines. There are no rigid protocols in combat, including TCCC. If the recommended TCCC combat trauma management plan does not work for the specific tactical situation that a combat medic, corpsman, or PJ encounters, then care must be modified to best fit the tactical situation. Scenario-based planning, then, is critical for success in TCCC.5,13
Changing the Culture in Battlefield Trauma Care
Several events that occurred prior to the onset of hostilities in Afghanistan were central to this transformation of battlefield trauma care. The Navy SEAL teams and the 75th Ranger Regiment began training all combatants in TCCC prior to the start of the current conflicts. The Army Special Missions Unit and the Air Force pararescue community also implemented TCCC from 1997 to 1998 and quickly adopted the practice of teaching TCCC to every combatant so that the most critical lifesaving interventions, like tourniquets, can be accomplished by every one of their unit members.9,50,51
After 10 years of intense combat operations in Iraq and Afghanistan by the Ranger Regiment, Kotwal and colleagues reported only one potentially preventable death among 32 combat fatalities (out of 419 casualties) sustained by the 75th Rangers,51 and the death that was deemed preventable occurred in the hospital, not the prehospital, setting. This finding stands in stark contrast to the 15% to 28% of preventable deaths reported in other studies among U.S. casualties in these conflicts.27,32,34Considering the prehospital phase only, potentially preventable deaths among fatalities in the 75th Rangers was zero as compared to 24% in the study by Eastridge et al.32 The remarkable disparity in potentially preventable deaths between early adopters of TCCC and the rest of the U.S. military was not widely known until the Kotwal study was published in 2011, followed by the Eastridge study in 2012. Observed differences in potentially preventable deaths may be due to differences in the methodology of determining which deaths are considered potentially preventable or differences between the casualty cohorts reported. Nevertheless, in 2017 little disagreement that the interventions pioneered by TCCC reduce preventable deaths during the phase of care when they are most likely to occur has been offered.
As noted earlier, the transition from previous prehospital trauma care regimens to TCCC was well under way in the U.S. military by 2011. This happened because of a very specific sequence of events that has been well documented but is not widely known. When U.S. forces invaded Afghanistan in 2001, there was no JTS in place and thus no mechanism for the systematic review of combat casualty care outcomes in the U.S. military to seek opportunities to improve care.52 Specifically, from 2001 to 2004, there was no DoD focus on the causes of preventable deaths among U.S. fatalities and how they could have been prevented, and TCCC was primarily used only by those units that had adopted these new concepts before 2001. Adoption of TCCC required a move away from long-standing and firmly entrenched approaches to battlefield trauma care. How did this widespread change of culture finally come about?
The first and most fundamental requirement for changing the culture in battlefield trauma care was to provide a much higher-quality set of recommendations. As recounted in recent publications,8,9,21 there were three aspects of the TCCC development process that enabled these improved recommendations. First, during the research effort that led to the development of TCCC, existing recommendations for prehospital combat trauma care were held to the same standards of evidence as those applied to proposed changes to that care. Second, the actual conditions that combat medical personnel were likely to encounter on the battlefield were considered in developing the new recommendations. Finally, input from combat medics, corpsmen, and PJs, our country’s primary battlefield trauma care providers, was sought and incorporated throughout the TCCC development process.
The second step in changing the culture in battlefield trauma care, and the one that first led to the spread of TCCC beyond the few early adopters, was the first preventable death review of U.S. fatalities from Iraq and Afghanistan. In 2004, the USSOCOM had two critically important questions that needed to be answered: (1) what specifically were our Special Operations combat casualties dying from, and (2) what, if anything, could have been done to prevent those deaths? One might reasonably assume that the DoD had always performed preventable death reviews on its combat fatalities, but, as of 2004, there was no formal process to review combat deaths and to use that information to save the lives of future casualties. USSOCOM called upon Col. John Holcomb, who was then the Commander of the USAISR, to help answer these questions. Col. Holcomb’s team found that in Special Operations forces, 15% of combat deaths resulted from injuries that were potentially survivable, and a number of those deaths might have been prevented with simple TCCC measures like a tourniquet.27 This study sent a clear signal that TCCC training and equipment were needed throughout the Special Operations community, as was methodology for an ongoing evaluation of the impact of these new battlefield trauma care techniques on morbidity and mortality.
The third step in changing the culture also resulted from a collaboration between USSOCOM and USAISR. After the documentation of preventable deaths in the Holcomb study, the leadership of USSOCOM supported the TCCC Transition Initiative, which expedited TCCC equipping and training of deploying USSOCOM units. The project was led by an 18-D Special Forces medic, SFC Dominic Greydanus, and not only provided TCCC trainingand equipment to deploying Special Operations units, but also collected feedback from medics, corpsmen, and PJs when these units returned from combat operations. It also provided early documentation of the success of TCCC interventions.8,21,37
The fourth event that led to the widespread adoption of TCCC concepts was a U.S. Central Command (CENTCOM) message that required that all combatants deploying to that theater be equipped with a tourniquet and a hemostatic dressing. This requirement was driven by the CENTCOM Surgeon at the time, Lt. Gen. Doug Robb. Although the services have the primary responsibility for training and equipping combatants, this mandate from CENTCOM forced supervising medical officers throughout the services to rethink their many years of medical training that had consistently taught them that the use of extremity tourniquets was a very bad idea.
The fifth key element that helped to change the culture of battlefield trauma care in the military was the excellent documentation of the impact of tourniquet use. It is often difficult to identify with precision which elements of TCCC are responsible for saved lives, but tourniquets are an exception to this rule. The work of Col. John Kragh, an orthopedic surgeon working at the Ibn Sina Hospital in Baghdad, reported that 31 lives were saved with tourniquets at his facility in one 6-month period.8,28-30 This finding, when extrapolated to all U.S. casualties sustained in Iraq and Afghanistan up to that point in time, indicated that, as early as 2008, well over 1,000 U.S. service members’ lives had possibly been saved with tourniquets in those conflicts. Again, these successes with tourniquet use were obtained without loss of limbs to tourniquet ischemia. Col. Kragh’s work irrefutably confirmed the lifesaving benefits of what was perhaps the single most controversial aspect of TCCC.8
The sixth essential step in changing the culture of the U.S. military to accept TCCC was effective strategic messaging. The success of the TCCC Transition Initiative, Col. Kragh’s work, and the decreased incidence of preventable deaths in units that were early TCCC adopters were presented frequently at military medical conferences and in the published medical literature.29,30,33,36,37,42,44,45,47 The dramatically lower proportion of preventable deaths in the 75th Ranger Regiment compared to that in the broader U.S. military in which TCCC was adopted later was widely acclaimed in the medical literature. This acclamation increased awareness among combat medical personnel and their physician and physician assistant supervisors of the success of TCCC in reducing preventable deaths. These reports also provided TCCC innovators with published evidence that they could present to their unit commanders.32,51
Finally, evidence alone is often not effective in driving advances in trauma care,21 and this and other difficulties inherent in making changes in battlefield trauma care have been identified.52,53 Divided lines of authority and distributed responsibilities in the military structure make it exceedingly difficult to optimize battlefield trauma care throughout the DoD. Butler, Smith, and Carmona described the problem this way:52
“Just as the United States has hundreds of trauma centers and thousands of autonomous prehospital care systems, which can potentially slow the transition of advances in military prehospital trauma care into use in the civilian sector, the U.S. Military has four armed services, six Geographic Combatant Commands, the U.S. Special Operations Command and the U.S. Transportation Command, all of which play a role in the care of combat casualties. Each of these organizations is authorized to operate autonomously with respect to combat casualty care unless directives are issued at the highest level of the military chain of command, which is the Secretary of Defense (SecDef) acting on the advice of his or her chief medical advisor, the Assistant Secretary of Defense for Health Affairs. Lacking direction in the form of SecDef rule and Joint Staff doctrine, there is no assurance that advances in trauma care will be implemented consistently throughout the various components of the US Military.”
Unfortunately, at the Secretary of Defense, Chairman of the Joint Chiefs of Staff, and Service leadership levels, the span of responsibilities is immense. The ability of leaders at this level to focus on and mandate aspects of trauma care that are vigorously debated even among trauma subject matter experts is very limited. Therefore, when change is effected in battlefield trauma care, it typically occurs at a significantly lower level in the military chain of command and benefits only those individuals in that part of the organization.
When TCCC was first proposed in 1996, the recommendations contained in the TCCC Guidelines were presented to a great many people in both civilian and military medical audiences. Even so, very little happened until Rear Admiral Tom Richards, then the Commander of the Naval Special Warfare Command, examined the evidence presented to him and mandated the use of TCCC throughout the Navy SEAL community. Admiral Richards was not a doctor, but his decision paved the way for saving hundreds of lives among U.S. combat casualties.8,9,21
A similar occurrence took place in the 75th Ranger Regiment. In 1997, the regiment’s commander, Col. Stanley McChrystal, acting on the advice of his Ranger medical personnel, made caring for Rangers wounded in combat one of his “Big Four” priorities by directive in 1997. The Big Four were marksmanship, physical training, small unit tactics, and . . . medical readiness.51 Col. McChrystal understood that on the field of battle, everyone has the potential to be a casualty, and everyone—not just medics—may be the first to encounter a casualty and to render lifesaving care. He expected that every Ranger was going to be engaged in casualty care, and so every Ranger received training in TCCC.21,54
Likewise, Gen. Doug Brown and VADM Eric Olson at the U.S. Special Operations Command mandated TCCC at a time when it was not the standard of care for prehospital trauma care, either in the U.S. military or in the civilian sector. General John Abizaid at the CENTCOM did much the same thing in requiring the use of tourniquets in Iraq and Afghanistan at a time when conventional wisdom dictated otherwise.
The first takeaway from this discussion of the importance of leadership in advancing battlefield trauma care is that new evidence alone does not drive advances in trauma care—in either the civilian sector or the military—people do that.
The second takeaway is that it is often not trauma subject matter experts who are the final decision makers in introducing new standards of trauma care. Both in the military and in the civilian sector, decision makers at senior levels are often not the subject matter experts. As former U.S. Surgeon General Rich Carmona pointed out during the Hartford Consensus IV meeting,55 it is the responsibility of innovative trauma care experts to inform and inspire senior leaders so that advances in trauma care can be resourced and implemented. It was the senior leaders noted here—all combat commanders, not physicians—who mandated that TCCC be implemented in the military. Effecting positive change in trauma care therefore takes strong senior leaders—acting on the advice of well-informed trauma subject matter experts—with a dedication to continuously improving trauma care and a willingness to invest both their professional reputations and resources to do so.21,54
From the Battlefields of Iraq and Afghanistan to Worldwide Use
Historically, many lessons learned from military combat casualty care have found application in civilian trauma care. This has also been true of TCCC. The United States has just had the longest period of continuous armed conflict in its history, and this has created a unique opportunity to understand and improve battlefield trauma care. Over the past 16 years of caring for combat casualties, many advances have been incorporated into TCCC as new evidence, new technology, and ongoing battlefield experience have accumulated. Many published reports from this period have highlighted the success of TCCC, and it is now used well beyond the U.S. military.
TCCC in Allied Militaries
TCCC has now been implemented by many coalition partnernations1 and has been recommended as the standard of care for combat first-aid training in member nations by the ABCANZ Armies (formerly America, Britain, Canada, Australia, New Zealand Armies’ Program).74 Canada was one of the earliest international adopters of TCCC. Savage and colleagues noted that, “although the Canadian military experienced increasingly severe injuries during the current conflicts, the Canadian Forces have experienced the highest casualty survival rate in history.”38 They further reported, “Though this success is multifactorial, the determination and resolve of CF leadership to develop and deliver comprehensive, multileveled TCCC packages to soldiers and medics is a significant reason for that and has unquestionably saved the lives of Canadian, Coalition, and Afghan Security Forces.” TCCC was also recommended as the battlefield trauma care standard for NATO partner nations by the NATO Special Operations–convened Human Factor and Medicine Expert Panel 224in 2011.75 Thanks in large part to allied participation in the TCCC Working Group and to the NAEMT’s worldwide educational infrastructure and its leadership in offering TCCC training to countries all around the world,21,73TCCC has indeed spread “all around the globe.”76
PHTLS and the American College of Surgeons Committee on Trauma
In 1996, the nascent TCCC effort benefitted from an interaction between Rear Admiral Mike Cowan, Commander of the Defense Medical Readiness Training Institute, and Dr. Norman McSwain, founder and medical director of the PHTLS program. These two leaders agreed that there should be a military medicine section in the fourth edition of the PHTLS textbook. TCCC concepts were included in that edition 77 and in every subsequent edition. This has been exceptionally helpful in that the PHTLS textbook carries the endorsement of the ACS and the NAEMT; this was the first step toward the mainstreaming of TCCC.8,9 Beginning with this initial interaction, a robust and ongoing dialogue developed between TCCC, PHTLS, and NAEMT. The strong partnership between NAEMT, PHTLS, the ACS-COT, and TCCC has endured, and these groups have adopted a number of the recommendations made by the CoTCCC regarding prehospital trauma care.78,79 TCCC, in turn, has benefitted greatly from many aspects of the PHTLS program and the NAEMT educational infrastructure.21,73
Hartford Consensus and Stop the Bleed
In recent years, civilian law enforcement officers and EMS responders have been called to bombing incidents, school and mall shootings, and other terror attacks that present tactical situations similar in some respects to those encountered on battlefields. The threat of ongoing hostile fire, treating multiple casualties under cover, and prolonged evacuation times have all come into play. Even in urban settings, getting to, treating, and transporting casualties scan require tactics and training outside the parameters of many standard EMS protocols. The mass casualty incidents at Columbine High School, Virginia Tech, Sandy Hook Elementary School, Stoneman Douglas High School in Parkland, Pulse Nightclub in Orlando, and the Las Vegas concert shooting are examples in point. More widespread adoption of applicable TCCC Guidelines into tactical EMS training programs, and application of these principles to tactical law enforcement operations may result in better tactical flow and additional lives saved.80
The dramatic increase in terrorist attacks and so-called active-shooter incidents creates the potential for a great many additional lives to be saved by using TCCC concepts. Public awareness of such events has caused tremendous acceleration in the usual interchange of information between military and civilian trauma care experts via initiatives like the Hartford Consensus,55,81,82 the White House Stop the Bleed campaign,83 TCCC-based courses offered by NAEMT, and the development of the civilian Tactical Emergency Casualty Care (TECC) program. These initiatives and many other local, state, and regional efforts have ensured that the advances in prehospital trauma care pioneered by TCCC, the JTS, and military medicine are being used to save lives in civilian trauma care practice with increasing frequency.84,86
TCCC and Wilderness Medicine
Another of the earliest and most productive of the partnerships formed by TCCC with civilian medical organizations was that between TCCC and the Wilderness Medical Society (WMS). The wilderness environment is similar in some respects to the battlefield. In both settings, the patient and the care provider are often in remote locations where evacuation may be delayed and complicated, significant and ongoing hazard may be present during the time that care is being provided, the equipment available for treatment is very limited, the environments may be extreme, and those providing care are often not paramedics, emergency physicians, or trauma surgeons.87,88 The overlap in the austerities of the combat and the wilderness settings has resulted in collaboration between military and wilderness medicine experts in many areas. TCCC emphasizes the need to consider the specific tactical scenario in formulating a treatment plan for a casualty, and many combat trauma scenarios occur in wilderness areas. TCCC and the WMS conducted a workshop in which they developed guidelines for combat casualty care in wildernesssettings.89 Fentanyl lozenges recommended for analgesia in TCCC90 were previously recommended for use in wilderness trauma care in 1999.91 Hemostatic dressings and tourniquets used in TCCC are the mainstays for controlling life-threatening external hemorrhage in the wilderness.92,93 TCCC-based techniques are now used to train medical personnel who provide care to trauma victims in our country’s national parks.94 A 2-day TCCC preconference held at the 2016 annual meeting of the WMS resulted in a supplement to the WMS-sponsored journal Wilderness and Environmental Medicine dedicated to topics in TCCC.88
The American College of Emergency Physicians (ACEP)
The endorsement of the ACS-COT of the TCCC-led use of prehospital tourniquets and hemostatic dressings has been discussed previously.55,78,81,82 The ACEP likewise endorsed tourniquets and hemostatic dressings for the control of life-threatening external hemorrhage in the prehospital setting.95
Additionally, the ACEP has endorsed some of the TCCC-led advances in prehospital analgesia. The survey of prehospital trauma care in Afghanistan in November 2012 led by Col. (retired) Russ Kotwal, Col. Stacy Shackelford, and Col. Erin Edgar, produced very valuable feedback from combat medical providers about the state of battlefield analgesia in U.S. forces.69 There was a clear and consistent message from medics, corpsmen, and PJs all over Afghanistan that they were happy with the analgesia options recommended by TCCC at the time, but that these options needed to be forged into a structured and coherent approach to battlefield analgesia. The JTS and the CoTCCC subsequently developed “Triple Option Analgesia.” This plan for battlefield analgesia provides faster, safer, and more effective relief of pain from combat injuries than the IM morphine that has been used by the U.S. Military since the Civil War.90 The Triple Option Analgesia plan incorporates the use of fentanyl lozenges pioneered by the 75th Ranger Regiment and the Army Special Missions Unit and ketamine pioneered by our colleagues in the United Kingdom and the U.S. Air Force PJ community. This plan customizes the analgesia choice to best suit the casualty’s level of pain and his or her physiologic status. The ACEP’s policy on out-of-hospital analgesia and sedation96 mirrors the Triple Option Analgesia plan. The agreement between these guidelines is compelling evidence that the Triple Option Analgesia plan is sound and that the lack of an FDA indication for fentanyl lozenges and ketamine as analgesics for acute pain does not preclude them from being best practice options based on available clinical evidence. This will be discussed more in the following section.
Summary and Take-Home Message
TCCC is different than civilian pre-hospital care. Battlefield considerations and conditions must be taken into account.
It is divided into 3 Phases (Care Under Fire, Tactical Field Care, and Tactical Evacuation Care).
Implementing the principles of TCCC has reduced preventable deaths on the battlefield.
References
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Understanding Combat Casualty Care Statistics
John B. Holcomb, MD, Lynn G. Stansbury, MD, Howard R. Champion, FRCS, Charles Wade, PhD, and Ronald F. Bellamy, MD
The Journal of TRAUMA, Injury, Infection, and Critical Care
J Trauma. 2006;60:397–401.
Description with Key Points:
The objective of this paper was to develop standardized terminology and equations that produce the best insight into the effectiveness of care at different stages of treatment. These equations were then applied consistently across data from the WWII, Vietnam and the current Global War on Terrorism (OIF/OEF). Three essential terms were clarified:
The Case Fatality Rate (CFR) as percentage of fatalities among all wounded
Killed in Action (KIA) as percentage of immediate deaths among all seriously injured (not returning to duty)
Died of Wounds (DOW) as percentage of deaths following admission to a medical treatment facility among all seriously injured (not returning to duty).
Using this clear set of definitions, the equations were used to ask two basic questions:
What is the overall lethality of the battlefield?
How effective is combat casualty care?
Mortality
World War II Vietnam Unconquered Freedom / Iraqi freedom.
Understanding battlefield medical care statistics.
Based on a comparison of statistics for battle casualties from 1941-2005, the U.S. casualty survival rate in Iraq and Afghanistan has been the best in U.S. history.
Why Are We Doing Better?
Improved Personal Protective Equipment
Tactical Combat Casualty Care
Faster evacuation time
Better trained medics
Death on the battlefield (2001-2011): Implications for the future of combat casualty care
Brian J. Eastridge, MD, Robert L. Mabry, MD, Peter Seguin, MD, Joyce Cantrell, MD, Terrill Tops, MD, Paul Uribe, MD, Olga Mallett, Tamara Zubko, Lynne Oetjen-Gerdes, Todd E. Rasmussen, MD, Frank K. Butler, MD, Russell S. Kotwal, MD, John B. Holcomb, MD, Charles Wade, PhD, Howard Champion, MD, Mimi Lawnick, Leon Moores, MD, and Lorne H. Blackbourne, MD
The Journal of Trauma and Acute Care Surgery
J Trauma Acute Care Surg, Volume 73, Number 6, Supplement 5
Description with Key Points:
Most battlefield casualties died of their injuries before ever reaching a surgeon. As most pre-medical treatment facility (pre-MTF) deaths are nonsurvivable, mitigation strategies to impact outcomes in this population need to be directed toward injury prevention. To significantly impact the outcome of combat casualties with potentially survivable (PS) injury, strategies must be developed to mitigate hemorrhage and optimize airway management or reduce the time interval between the battlefield point of injury and surgical intervention.
Understanding battlefield mortality is a vital component of the military trauma system. Emphasis on this analysis should be placed on trauma system optimization, evidence-based improvements in Tactical Combat Casualty Care guidelines, data-driven research, and development to remediate gaps in care and relevant training and equipment enhancements that will increase the survivability of the fighting force.
Death on the battlefield (2001 - 2011): Implications for the future of combat casualty care
Prehospital care is the most important aspect in ensuring the survival of the casualty.
Almost 90% of all combat deaths occur before the casualty reaches a Medical Treatment Facility (MTF)*
The fate of the injured often lies in the hands of the first responder. Of the prehospital deaths, 24.3% were deemed potentially survivable. (n = 976)
Initial care may have to be provided by the combatant.
While hemorrhage remains the number one cause of death, the second most common cause (8%) of potentially preventable deaths was upper airway obstruction due mostly to direct injury to the airway structures of the face and neck. (n = 78)
TCCC has helped U.S. combat forces to achieve the highest casualty survival rate in history.
A Profile of Combat Injury
Howard R. Champion, FRCS(Edin), FACS, Ronald F. Bellamy, MD, FACS, COL, US Army, Ret., Colonel P. Roberts, MBE, QHS, MS, FRCS, L/RAMC, and Ari Leppaniemi, MD, PhD
The Journal of TRAUMA, Injury, Infection, and Critical Care
J Trauma. 2003;54:S13–S19.
Description with Key Points:
Traumatic combat injuries differ from those encountered in the civilian setting in terms of epidemiology, mechanism of wounding, pathophysiologic trajectory after injury, and outcome. Except for a few notable exceptions, data sources for combat injuries have historically been inadequate. Although the pathophysiologic process of dying is the same (i.e., dominated by exsanguination and central nervous system injury) in both the civilian and military arenas, combat trauma has unique considerations with regard to acute resuscitation, including:
he high energy and high lethality of wounding agents;
multiple causes of wounding;
reponderance of penetrating injury;
ersistence of threat in tactical settings;
ustere, resource-constrained environment; and
(elayed access to definitive care.
Recognition of these differences can help bring focus to resuscitation research for combat settings and can serve to foster greater civilian-military collaboration in both basic and transitional research.
Key Chart:
Causes of mortality in military operations (from the work of Colonel Ron Wellamy).
9% of those killed in battle – Bleeding due to limb injuries
31% of those killed in battle are CNS lesions
1% of those killed in battle – Airway obstruction
7% of those killed in battle – Explosive crippling injuries
5% of those killed in battle – Tension pneumothorax
12% died from wounds - mainly infections and complications of shock
25% of those killed in battle – Injuries to the torso that are not amenable to surgical treatment
10% of those killed in battle – Lesions on the torso that are amenable to surgical treatment
The Wound Data Munitions Effectiveness Team (WDMET) database suggests that exsanguination from extremity wounds accounts for more than half of the potentially preventable deaths in combat, thus the continued emphasis on hemostasis as the primary maneuver in combat casualty care and the research emphasis on agents that might provide a means of decreasing inaccessible or uncontrollable hemorrhage. Other potentially preventable deaths include simple airway obstruction and other sources of hemorrhage that are surgically remediable if such care can be provided in a timely fashion.
We can use this data to help us understand what types of injuries are seen in combat and which may or may not be survivable.
The causes of death for Soldiers who died in Vietnam demonstrates that a significant number of deaths occur from problems addressed by TCCC, including exsanguination from extremity wounds, airway obstruction, and tension pneumothorax.
Injury Severity and Causes of Death from OIF and OEF, 2003-04
Injury Severity and Causes of Death From Operation Iraqi Freedom and Operation Enduring Freedom: 2003–2004 Versus 2006
Joseph F. Kelly, MD, Amber E. Ritenour, MD, Daniel F. McLaughlin, MD, Karen A. Bagg, MS, Amy N. Apodaca, MS, Craig T. Mallak, MD, Lisa Pearse, MD, Mary M. Lawnick, RN, BSN, Howard R. Champion, MD, Charles E. Wade, PhD, and COL John B. Holcomb, MC
The Journal of TRAUMA, Injury, Infection, and Critical Care
J Trauma. 2008;64:S21–S27.
Description with Key Points:
The opinion that injuries sustained in Iraq and Afghanistan have increased in severity is widely held by clinicians who have deployed multiple times. To continuously improve combat casualty care, the Department of Defense has enacted numerous evidence-based policies and clinical practice guidelines. Overall causes of death were examined, looking for opportunities of improvement for research and training.
In the time periods of the war studied, deaths per month has doubled, with increases in both injury severity and number of wounds per casualty. Truncal hemorrhage is the leading cause of potentially survivable deaths. Arguably, the success of the medical improvements during this war has served to maintain the lowest case fatality rate on record.
Key Chart:
Potentially preventable deaths (232) in the initial phase of Operations Enduring Freedom and Iraqi Freedom (OIF/OEF)
Multisystem organ failure (4%)
Respiratory tract (14%)
31% can be stopped by squeezing (pre-hospital stage)
69% cannot be stopped by squeezing (forward surgical team / combat support hospital)
Bleeding 85%
From a study of 982 injury cases, the victim may have more than 1 cause of death (KellyJ., J Trauma 64:S21, 2008)
Injury Severity and Causes of Death From OIF and OEF: 2003-2004 Versus 2006.
More recent data from Iraq and Afghanistan show hemorrhage is still the major cause of potentially preventable deaths. We are doing better than ever in regards to managing preventable deaths on the battlefield, but studies show we still have room for improvement.
