Module 1: Principles and Application of Tactical Combat Casualty Care (TCCC)

Welcome to the Combat Paramedic or Provider, or CPP, course for Tactical Combat Casualty Care.

Recognizing that Tactical Combat Casualty Care (TCCC) is the standard of care in battlefield prehospital medicine, DoDI 1322.24, Medical Readiness Training, implemented standardized combat casualty care training for all Service members.1 This training focuses on lifesaving skills and is tailored to the level of care that an individual might be expected to perform. If you have not been trained in TCCC, then your previous medical training may not have contained the material presented in the following lessons.

Tactical Combat Casualty Care is broken up into four roles of care:

1. The most basic is All Service Members (ASM) and includes the absolute basics of hemorrhage control and basic recognition of more serious problems.
2. The Combat Lifesaver (CLS) is taught more advanced skills needed to treat the most common causes of preventable death due to traumatic injuries including hemorrhage (from the extremities / junctional areas), tension pneumothorax, and airway trauma or obstruction. They are also taught to identify and treat other not immediately life-threatening injuries.
3. The Combat Medic/Corpsman (CMC) is the first medical provider to care for the casualty in the prehospital environment and is expected to provide more advanced care requiring significantly more medical knowledge and skills.
4. The most advanced role is yours, as the CPP, and you are expected to provide the most sophisticated care to keep our wounded warriors alive and get them to definitive care.

Feedback from trainers and trainees indicated that the prior methods for TCCC training were heavy in PowerPoint slides, and that more time performing procedures and applying those principles to realistic scenarios would be beneficial. Also, updates seemed to take months to make it to the field for implementation. Responding to that feedback, the decision was made to develop a web- and mobile-based platform for both classroom support and job performance support outside of the classroom. Deployed Medicine2 is the result of those efforts and is a continuously evolving platform where you can find classroom materials and other aids to learn more about TCCC.

This CPP course builds on the CMC TCCC course, previously known as the TCCC Medical Provider (TCCC-MP) course, but adds additional information and skill requirements tailored to your level of training. The course objectives reflect the priorities that the Joint Service Working Group, commissioned by the Defense Health Agency, the Committee on Tactical Combat Casualty Care, and Joint Trauma System, felt were important for CPP personnel. These are the 27 different modules we will cover.

This first module will focus on the basic principles and application of TCCC. At the end of the course, you will be expected to demonstrate the application of TCCC skills in a practical exercise. This module, along with those that follow, will set the stage for you to successfully complete that demonstration.

Throughout the course, you’ll see the enabling learning objectives listed as cognitive or psychomotor. The cognitive objectives are knowledge-based, while the psychomotor objects require that you learn and demonstrate a skill.

There are 13 cognitive learning objectives for this first module listed on this slide. Unlike future modules that primarily focus on clinical knowledge and skills, this module will help you understand the basis for the development of TCCC and its value to the warfighter, as well as help prepare you to be able to oversee training for others in your organization.

To help set the stage for this module and the course, let’s begin with an introduction video that overviews Tactical Combat Casualty Care (TCCC).

# INTRO TO TACTICAL COMBAT CASUALTY CARE (TCCC) OVERVIEW

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The leading causes of preventable combat death due to traumatic injuries include hemorrhage, from the extremities/junctional areas, tension pneumothorax, and airway trauma or obstruction.3 By far, the majority of preventable deaths were from massive hemorrhage.

Throughout this course, you will notice the emphasis on controlling bleeding, whether that be through tourniquet placement on the extremities, the use of hemostatic dressings and wound packing, or the use of junctional tourniquets. But we still need to be cognizant of respiration and airway issues and be prepared to do needle decompression of the chest or chest tube insertions and control the airway through airway maneuvers or advanced airway procedures.

As you observed during the video, TCCC has three main phases of care.4

- Care Under Fire (CUF)/Threat
- Tactical Field Care (TFC)
- Tactical Evacuation Care (TACEVAC).

Each has specific considerations to keep in mind, both for the threats that may impact what care can be delivered and the priorities for treatment.

The first phase is Care Under Fire, or in the case of a noncombat environment, Care Under Threat. In this phase, the scene is not safe, and the overall priority is to establish scene safety in the form of fire superiority or control of any threats from a noncombat environment. The TCCC Guidelines outline seven steps for the basic management plan for Care Under Fire:5

1. Return fire and take cover.
2. Direct the casualty to remain engaged as a combatant if appropriate.
3. Direct the casualty to move to cover and apply self-aid if able or when tactically feasible, move or drag casualty to cover.
4. Try to keep the casualty from sustaining additional wounds.
5. Casualties should be extracted from burning vehicles or buildings and moved to places of relative safety. Do what is necessary to stop the burning process.
6. Stop life-threatening hemorrhage if tactically feasible.

1. Casualties should be extracted from burning vehicles or buildings and moved to places of relative safety. Do what is necessary to stop the burning process.

2. Stop life-threatening external hemorrhage if tactically feasible:

1. Direct casualty to control hemorrhage by self-aid if able.
2. Use a CoTCCC-recommended limb tourniquet for hemorrhage that is anatomically amenable to tourniquet use.
3. Apply the limb tourniquet over the uniform clearly proximal to the bleeding site(s). If the site of the life-threatening bleeding is not readily apparent, place the tourniquet “high and tight” (as proximal as possible) on the injured limb.

3. Move the casualty to cover.

During Tactical Field Care, the TCCC Guideline basic management plan includes the following steps:6

- Establish a security perimeter in accordance with unit tactical standard operating procedures and/or battle drills and maintain tactical situational awareness.
- Triage casualties as required. Casualties with an altered mental status should have weapons and communications equipment taken away immediately.
- Assessment and treat following the MARCH PAWS sequence.
- Communicate.
- Document.
- Prepare for evacuation.

Keep in mind that Tactical Field Care can always revert to a Care Under Fire situation if scene safety is compromised. This is why there is such an emphasis on maintaining situational awareness of the surroundings and not using all of your resources to focus on casualty care.

Supplies in the field are usually limited. Exercise care by using the casualty’s JFAK initially; then use the supplies from your unit’s combat lifesaver kits (if available) or whatever Combat Medics/Corpsmen may have brought in their CMC aid bag before beginning to use your CPP supplies and equipment.

And, as always, be sure to prioritize your assessment and treatments by following the MARCH PAWS sequence we mentioned earlier.

Before moving on to the Tactical Field Care phase, this is a good time to introduce the MARCH PAWS approach and how it can help you decide on assessment and treatment priorities.

MARCH is a mnemonic to remind you of the sequence of priorities for assessing and treating potentially life-threatening issues during the Tactical Field Care phase, beginning with massive bleeding. Any time your assessment reveals the need for an intervention or treatment, pause the assessment to complete the treatment and then resume the assessment where you left off.

PAWS is also part of Tactical Field Care if the tactical situation permits and/or if you have no other casualties that require your attention for immediate life-threatening issues. You’ll see this throughout the course, and it will also be helpful during your practical exercises.

Throughout the rest of the course, we will cover the interventions and procedures of MARCH PAWS in more detail. Although we’ll take a moment to highlight some key concepts that apply throughout the TTA, we’ll defer discussions about the specific interventions until their corresponding module. For now, the focus should be more on the process than on the details of each procedure.

Remember that when performing an assessment, you will need to go back and forth from assessing the need for an intervention to performing a skill, and then return to assessing for the next potential injury. So, although we call this an assessment, the entire process is a combination of an assessment and a treatment plan being executed simultaneously.

The basic management plan for transition of care from TFC to TACEVAC is also outlined in the TCCC Guidelines,7 and involves five steps:

1. Tactical force personnel should establish evacuation point security and stage casualties for evacuation.
2. Tactical force personnel or the medic should communicate patient information and status to TACEVAC personnel as clearly as possible. The minimum information communicated should include stable or unstable, injuries identified, and treatments rendered.
3. TACEVAC personnel should stage casualties on evacuation platforms as required.
4. Secure casualties in the evacuation platform in accordance with unit policies, platform configurations and safety requirements.
5. TACEVAC medical personnel should re-assess casualties and re-evaluate all injuries and previous interventions.

In summary, your casualty is likely to go through three distinct phases of care between point of injury and evacuation to a higher level of care. Each has different limitations and dictates different approaches to casualty assessments and treatments.

Some of the key points of the basic management plan are summarized on this slide. The individual modules you go through later in the course will provide even more detail.

The principles of TCCC apply to trauma in both combat and noncombat settings.8,9 Severe bleeding or an amputation from a motor vehicle accident requires the same assessment and treatment you would render to a combatant who was injured from an IED blast. An active shooter produces the same ballistic injuries as an enemy combatant. Workplace accidents, vehicle rollovers, fires, explosions, burns, or other training accidents have accounted for a significant number of military noncombat injuries, all of which can be approached using the same principles of TCCC.

Although the principles of TCCC apply to trauma in both combat and noncombat settings, the environmental differences can play a significant role in how those principles are applied.

For example:

- Hostile fire
- Darkness
- Environmental extremes
- Different wounding epidemiology
- Limited equipment
- Need for tactical maneuver
- Long delays to hospital care
- Different medic training and experience

If a ballistic injury occurs in an urban setting with highly capable trauma surgery assets and rapid evacuation to a nearby civilian or military hospital, the issues surrounding assessment, treatment options, and casualty evacuation preparation will be very different than in an austere hostile setting, where a higher level of care is not readily available and responders are working in an austere location. TCCC Guidelines and training were developed assuming that most scenarios would lack nearby advanced trauma and evacuation assets.

CPP personnel are not alone in providing medical care from the point of injury through evacuation to a more advanced role of care. All Service members are required to have some basic medical training.

With the new medical readiness training instruction, this is changing from prior Service-specific basic first aid or self-aid and buddy care training to the DHA standardized TCCC-All Service Members (ASM) training, though Services may still have additional medical training that they add based on their mission and risks associated with that environment.

In addition to the ASM personnel's basic understanding of the MARCH sequence, they will be trained on five lifesaving skills:10

- Rapid casualty assessment
- Tourniquet application
- Hemostatic dressing/wound packing
- Pressure bandages
- Basic airway maneuvers

The Combat Lifesavers (CLS) are nonmedical military personnel with additional trauma training beyond basic first-aid procedures. The additional duties of CLS are to provide enhanced first aid for injuries based on their training before more advanced medical care arrives.

During the Care Under Fire phase, they will focus on gaining fire superiority and preventing further risk to casualties but can also apply self-aid principles and assist in casualty movement, if tactically feasible. In the Tactical Field Care phase, they can independently perform a casualty assessment and render any MARCH PAWS treatments that they have been trained to perform, though they may need to return to the fight if the situation changes. Also, the CLS can support CMC personnel and receive additional guidance and direction from them, as appropriate.

Combat Medics/Corpsmen are responsible for specialized first aid, triage, resuscitation, and stabilization, as well as casualty collection from the point of wounding and preparation of casualties for evacuation to a higher role of care. In CUF, their role is to first suppress hostile fire like the CLS, but in TFC they assume the primary role for casualty assessment and treatment, following the TCCC Guidelines.

In addition, they can manage and direct the on-scene casualty response efforts utilizing all available responders, providing guidance and direction to their activities. They are also responsible for preparing the casualties for evacuation.

In the TACEVAC phase, they are responsible for reassessing the casualties immediately before the arrival of the evacuation assets, communicating findings to the TACEVAC medical personnel, ensuring proper staging, and supporting the loading and securing of casualties on the evacuation platform.

As a Combat Paramedic or Provider, you have the same responsibilities as the Combat Medic when functioning as the unit medic. In CUF, you also suppress hostile fire like the CLS and CMC, and in TFC you assume the primary role for casualty assessment and treatment, following the TCCC Guidelines. But there are some procedures and situations that your more advanced training may allow you to address closer to the point of injury than in cases where CMCs do not have immediate access to more advanced providers. Also, like the CMC-level provider, you will manage and direct on-scene casualty response efforts, coordinating the activities of other responders, both medical and nonmedical.

Additionally, you play a key role in ensuring that the training programs for the medics in your unit are preparing them for their deployed roles, and for the overall direction of the Role 1 medical response system.

Several factors influence the delivery of TCCC and are worth mentioning, as understanding them can help you prepare yourself and your CMC or CLS personnel to deliver better care.11 Some of these were partially highlighted when we described the application of TCCC in different environments but warrant being repeated because of their importance. Although not inclusive, these factors include:

- Hostile environments – if you are not under fire, that risk is always present and requires some of your attention.
- Tactical environments – your situation will dictate your movements and communication options, as well as access to support personnel.
- Wound pattern differences – depending on your mission profile, you may anticipate different threats which may make certain injury patterns more likely.
- Environmental considerations – more often than not, you will need to deal with poor lighting, austere conditions, and maybe inclement weather.
- Unknown response personnel capabilities – in the best-case scenario, you will have had time to train and work with your ASM, CLS, and CMC personnel, but that is not always the case.
- Resource limitations – tactical considerations may limit what you can take with you, and resupply can be erratic (or nonexistent).
- Evacuation delays – the potential for significant delays may lead to prolonged field care issues.

It’s impossible to understate the value of training in TCCC. In addition to anecdotal stories about how TCCC has saved lives, irrefutable scientific evidence shows that TCCC principles will prevent deaths.12 Units that have mandated initial and sustained training requirements have been shown to have better retention of knowledge and skills, which will translate into improved performance in an operational setting. Military units that have trained ALL of their members in TCCC have documented the lowest incidence of preventable deaths among their casualties in the history of modern warfare.13

In addition to the individual training on specific skills, unit-based training teaches the medical personnel and combat lifesavers/first responders how to work as a team, allowing them to be much more efficient when faced with a real-life situation.14

Remember, the ongoing mission does not stop just because there is a casualty. The three objectives of TCCC are to:

- Treat the Casualty – provide lifesaving care to the injured combatant.
- Prevent Additional Casualties – limit the risk of taking further casualties.
- Complete the Mission – enable the unit to achieve mission success.

This slide depicts a study that was done on soldiers who died in Vietnam. Two thousand and five hundred preventable deaths from extremity hemorrhage were the result.15 Tourniquets could have saved these lives.

Twenty-five years later, we had still not learned the tourniquet lesson from Vietnam. Instead, 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.

In this group of patients from Mogadishu Somalia in 1993, uncontrolled hemorrhage caused 22% of the fatalities.16 Hemorrhage continued to be a major cause of battlefield death and is the leading cause of combat death when evacuation is delayed for more than 6 hours.

The soldier who slowly exsanguinated from a proximal femoral artery and vein injury despite the efforts of a medic and others to stop the bleeding is a particularly poignant example. This again illustrates the point made by Bellamy in 1984,17 when in his discussion on improving the salvage of combat casualties, he stated, “First and foremost, there is a need to improve the field management of hemorrhage.”

Clearly, the management of choice for severe extremity hemorrhage is an effective tourniquet followed by surgical repair or ligation of the injured vessels. The incidence of fatal head wounds was similar to that in Vietnam in spite of modern Kevlar helmets. Body armor reduced the number of fatal penetrating chest injuries. Penetrating wounds to the unprotected face, groin, and pelvis caused significant mortality.

But what about injuries not amenable to a tourniquet, such as those to the lower abdomen, groin, axilla, and proximal extremities? What is the optimal management for these patients on the urban battlefield of the future, where evacuation may be significantly delayed?

Tactical medical training historically was modeled on civilian courses like the Emergency Medical Technician (EMT) and Advanced Trauma Life Support (ATLS) courses and mirrored civilian trauma resuscitation guidelines, which provided excellent in-hospital care and results. But the principles they reflect often needed to be modified for the tactical setting, and that was not routinely done.18

In previous conflicts, the use of tourniquets was discouraged, crystalloid fluid resuscitation was used for shock, hemostatic agents were not available, and airways were established through endotracheal intubation. At the start of the war in Afghanistan, TCCC was used only by a few innovative units in the US military.19 The impact of this limited use of TCCC was not well-appreciated until the first preventable death analysis was conducted.20 That study by Holcomb and others found that 8 of the 12 individuals who died from injuries that were potentially survivable might have been saved simply by the proper application of TCCC principles.

The experience with limb tourniquets was largely responsible for the adoption of TCCC throughout the US military.21 Tourniquets were a high-visibility issue for two reasons. First, tourniquet use was a radical departure from prehospital trauma care practice. Second, ubiquitous tourniquet use has clearly been the single most important lifesaving battlefield trauma care advance achieved during the wars in Iraq and Afghanistan.22,23

The strategic messaging on tourniquets that drove the spread of TCCC from the Special Operations community to the conventional forces included reports of preventable death from extremity hemorrhage and documentation of improved survival as the use of extremity tourniquets became more prevalent. Now, in addition to evidence-based tourniquet guidance, many other TCCC advances have been adopted, such as hemostatic agents, needle decompression of the chest (NDC), advanced/surgical airways, resuscitation with blood products, and hypothermia prevention. These have not only had positive impacts on military prehospital trauma care but also have been widely adopted in the civilian community.24

TCCC training methods that ensure unit readiness and support the achievement of no losses due to preventable combat deaths is a primary responsibility for the CPP, whether that be as the primary medic for a unit or as medical director overseeing the Role 1 medical system involving additional medical resources.

The establishment of standardized training programs and resources will help to correct some of the disparities that have been seen between units and Services, but is not, in and of itself, the complete solution to a robust training platform that ensures maximum readiness. Even with the prior standardized TCCC-All Combatant and TCCC-Medical Provider materials and National Association of Emergency Medical Technician-certified instructors, there was significant variation within training programs in a 2018 TCCC baseline training assessment for the Defense Health Agency.25

The main findings responsible for the variations were inconsistent or inadequate instructor training and selection, variable methods of assessment, lack of adequate physical space for both classroom and practical training, and variations in simulation capabilities. A common finding during the assessment was that units did not prioritize TCCC training for either their medics or their other personnel.

To ensure your TCCC training programs are optimized, several issues should be highlighted:

- Ensure that your line leadership understands the need for prioritizing TCCC training
- As core training plan and materials, use the approved Joint Trauma System resources
- Make sure all instructors are properly trained & stay up-to-date with curriculum changes
- Incorporate real-world experiences and case scenario-based examples in the training
- Provide the most realistic training environment you can
- Use standardized assessments with constructive feedback and remediation, as needed
- Incentivize ongoing training outside of formal classes (e.g., Deployed Medicine)

TCCC, as a formalized set of guidelines and subsequent evolvement into a curriculum began with the 1996 publication of the first set of TCCC Guidelines in an article by CAPT Frank Butler.26 But many of the concepts and experiences that led to that publication occurred in the years prior and drew from articles and research that dated back as far as our previous conflicts but was never institutionalized.27,28

In the late 1990s, these concepts of TCCC were presented to the Joint Staff Surgeon and subsequently to senior leaders of the Military Health System, but no specific plan of action emerged from the briefings. They were also presented at a series of both military and civilian medical conferences, but there was no DoD-level effort to revamp prehospital combat casualty care practice.29

However, the Naval Special Warfare Command, the 75th Ranger Regiment, the Army Special Missions Unit, and the Air Force pararescue community all individually adopted the guidance and were the only units implementing the Guidelines at the start of the war in Afghanistan.30 Afterwards, as we just mentioned, the concepts and guidance spread from these innovative units to the general purpose forces, and most recently has been adopted as the standard of care for medical training for all Service members, Combat Lifesavers, and medical personnel.

In 2001, a medical research effort by the U.S. Special Operations Command (USSOCOM) led to the development of a Committee on TCCC (CoTCCC), which was first established at the Naval Operational Medicine Institute. A significant aspect of the committee composition is that 30% of the voting members should be comprised of active or former combat medics and paramedics, corpsmen, and pararescuemen (PJs). The remainder of the 42-person voting membership includes all Services, various surgical specialties, emergency medicine and combat medical educators, including physicians, physician assistants, nurses and medical planners.

After several years as a research-funded activity, the CoTCCC was moved to the Defense Health Board in 2007 and subsequently to the Joint Trauma System (JTS) in 2013 after it was formally established.31 Although the JTS has been realigned a few times since 2013, CoTCCC has remained a primary JTS committee and priority throughout its evolution.

The CoTCCC mission is “To develop on an ongoing basis the best possible set of trauma care guidelines customized for the tactical environment and to facilitate the transition of these recommendations into battlefield trauma care practice.”32 Guideline updates have occurred periodically since 1996, the first time in 200333 up through the most recent version released in November of 2020. In addition to routine meetings involving the entire COTCCC membership, subcommittees and specialized ad hoc groups are formed, as needed, to address specific issues that may ultimately be presented to the larger group for consideration.

The recommendations of CoTCCC and the TCCC Guidelines they produce form the backbone of TCCC training and prehospital care for the DOD. Recent policy statements from the Assistant Secretary of Defense for Health Affairs highlight the importance of these guidelines and recommendations in training34 and choosing lifesaving material (equipment for use in TCCC),35 in addition to the DOD instruction on TCCC training for All Service Members.36

Although the importance of the CoTCCC Guidelines and recommendations is highlighted by the emphasis placed on it through policy statements, the impact that the guidance has had on casualty outcomes really validates their importance. Beginning with initial studies that demonstrated improved survival when responders followed TCCC guidance,37,38 research has shown that adhering to the recommendations of CoTCCC and using the TCCC Guidelines positively affects casualty outcomes.39,40,41

A primary reason that the recommendations and guidance remain important tools for prehospital medical personnel is that they are not based on anecdotal experiences or outcomes from individual scenarios but use an evidence-based approach that is augmented by the subject matter expertise of very combat-experienced professionals. This applies not only to the treatment guidelines and clinical practice guidelines but to recommendations for equipment and TCCC training.

Another important point to highlight is that the landscape of prehospital medical care is constantly changing and evolving. As we enter an era where we may be involved in more anti-access and area denial missions that use units with smaller footprints in environments that are less permissive, the need for prolonged field care will likely become more important with longer evacuation times. New technologies will continue to be developed that enhance forward delivery of medical care. In this ever-changing environment, guidelines and recommendations will need to adapt and change.

CoTCCC and the JTS have a process to ensure the TCCC Guidelines remain relevant and stay updated. The first step is the identification of issues that could be considered for a formal review. These range from the advent of new technologies and equipment, to the findings of combat casualty care reviews through the DOD Trauma Registry or other research efforts, to lessons identified in current operations, to routine reviews of existing recommendations to ensure they are founded on sound evidence-based guidance. Often this comes through CoTCCC members at routine meetings, but it can certainly be identified by other medics based on their knowledge, experiences or research.

Potential issues are then identified to select CoTCCC members for consideration. Sometimes, the need to pursue the issue further is very obvious, and it will move to the next stage without being introduced to the entire CoTCCC membership. Other times, the issue will be forwarded to the larger membership body for consideration as a new project (either at an in-person meeting or through a less formal process of reaching out to the members individually). Based on the collective response, the issue may move to the next stage, but sometimes the choice is to not pursue the issue further at that time, leaving room open to readdress the issue at a later date.

The next stage involves the selection of a small group of people, led by a champion, to address the issue and prepare a course of action and recommendations for the CoTCCC membership. This stage could involve doing a retrospective review of literature, it might require some deliberate research (particularly in the cases of new technology recommendations), and it almost always involves coordination with subject matter experts inside and from outside of CoTCCC membership. The end result of this most complicated phase is a set of recommendations for the CoTCCC membership to consider.

Once that information has all been gathered and put together, the issue is brought before the CoTCCC members for deliberation. This can be done at the routinely scheduled CoTCCC meetings (often held twice a year), but an ad hoc meeting can also be convened. A routine meeting either is limited in time or will not occur in time to address a time-sensitive issue. Read-aheads are provided, but there is an open discussion, and debate is encouraged prior to voting. The membership ultimately votes on anything that might result in a Guideline change or formal CoTCCC recommendation. The minutes from those meetings are openly available on the JTS website.

Changes to the Guidelines may be validated, but a completely new version might not be issued pending other outstanding issues, to prevent version changes from occurring too frequently (CoTCCC may choose to reissue the Guidelines once several changes are approved). In the interim, each pending change will be highlighted so anyone who might be affected can prepare for the upcoming modifications. Also, in the case of most changes, a formal change paper is written, providing a summary of the information that formed the basis for the CoTCCC discussions. These are often published in the Journal of Special Operations or in Military Medicine.

Throughout the course, you will see comments referring to the evidence behind guidelines and recommendations. Evidence-based recommendations and guidance are the result of a careful review of studies and discussion by a panel of subject matter experts. For TCCC, the subject matter expert panels include both Committee on TCCC members, and select invited subject matter experts from within both the military and civilian community, based on the specific interest area.

A common approach is the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, which rates the quality of evidence, then balances that with the outcomes (desirable and undesirable) to provide a recommendation with a comment about the certainty of the evidence. But there are other similar methodologies used by professional organizations, as well.

The quality of the evidence looks at variables like the number of studies on the area of interest, any limitations of the study, biases, consistencies, sample sizes, and statistical strengths of the results, among other things. In general, randomized, controlled studies with statistically significant findings are graded higher and observational studies with equivocal to mildly significant findings are graded lower. And consensus subject matter expert opinions without observational (or randomized) studies are also graded lower.

But keep in mind, that in the absence of clear evidence from formal studies, the use of consensus opinions is considered a best practice, which should be accompanied by simultaneous research to study that area of interest and ultimately provide evidence to support that opinion or alter the recommendation.

Guyatt G, et al. GRADE guidelines: 1. Introduction – GRADE evidence profiles and summary of findings tables. J Clinical Epidemiology. 64(2011):383-394.

Guyatt G, et al. GRADE guidelines: 1. Introduction – GRADE evidence profiles and summary of findings tables. J Clinical Epidemiology. 64(2011):383-394.

The mission of the Joint Trauma System (JTS) is to improve trauma readiness and outcomes through evidence-driven performance improvement. And the vision of the Joint Trauma System is that every Soldier, Sailor, Airman, and Marine injured on the battlefield or in any theater of operations will be provided with the optimum chance for survival and maximum potential for functional recovery.42

Military trauma system deficiencies were noted in reports from Operation Desert Shield and Desert Storm in 1992.43 Then, after the terrorist attacks of September 11, 2001, the increase in armed conflict and subsequent battlefield injuries again raised questions about how to improve the military trauma response, as the absence of trauma experts and a trauma system was glaring.44

COL John Holcomb, MD, was deployed to examine the trauma system and make recommendations for improvement. The result was a Central Command Joint Theater Trauma System (JTTS), which later became the Joint Trauma System in 2006.45,46 After several organizational changes, it has been designated as the lead agency for trauma in DoD with authority to establish and assure best-practice trauma care guidelines.47

The JTS consists of six principal entities:48

- DOD Trauma Registry Management
- Defense Committee on Trauma
- Performance Improvement
- Combatant Command Trauma System Management
- Joint Trauma Education and Training
- Defense Medical Readiness Institute

The Committee on Tactical Combat Casualty Care is a committee under the Defense Committee on Trauma, along with the Committee on En Route Combat Casualty Care and the Committee on Surgical Combat Casualty Care.

Several key JTS functions play roles in combat casualty care at the unit level:

- Developing and maintaining evidence-supported clinical practice guidelines (CPGs) – supporting the unit medics with concise and subject matter expert-vetted TCCC Guidelines and other CPGs.
- Recommending combat casualty care training requirements – providing resources and training recommendations for unit personnel, both medical and nonmedical.
- Evaluating and recommending new equipment or medical supplies – providing units with well-researched objective advice on equipment and supplies so that they do not need to do independent research.
- Facilitating medical performance improvement by promoting real-time, data-driven clinical process improvements and improved outcomes – providing units with up-to-date information to help tailor unit training and procedures more rapidly than in prior years.
- Improving communication and facilitating movement, collection, and sharing of theater combat casualty data across all roles of care and all the Military Services – supporting the key roles of communication and documentation at a unit level, in addition to higher levels.
- Maintaining the Department of Defense Trauma Registry (DoDTR) on DoD injury demographics, care provided, and outcomes – supporting communication with unit leadership and identifying any unit-specific trends.
- Improving the organization and delivery of trauma care – helping unit medics to organize, train and equip in support of their leadership and unit personnel. The JTS website has many documents and other information that can answer trauma-related questions and help you manage unit TCCC training. Additionally, their contact information has different links for the various JTS functions that you might need to access at a unit level.

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 Department of Defense-sponsored committee established for this purpose – the Committee on Tactical Combat Casualty Care, or CoTCCC. The TCCC Guidelines are reviewed quarterly and updated as needed by CoTCCC.

The guidelines are published in a few places; however, Deployed Medicine is the official website to get the most up-to-date TCCC materials. Even though it is a .com website, it is an official site owned and managed by the Department of Defense. As soon as TCCC Guideline updates are approved for distribution by the Director of the Joint Trauma System (JTS), they will be updated directly onto Deployed Medicine.

Respiration assessment and management is a vital Tactical Field Care skill that includes recognition and treatment of tension pneumothorax, one of the most common causes of preventable death on the battlefield.

We began by reviewing the basic concepts and signs and symptoms of respiratory distress and life-threatening chest injuries. Then we discussed open pneumothorax, focusing on the pathophysiology to understand why chest seals are recommended and how they work. We also talked about the evidence supporting the recommendation to use vented chest seals when they are available.

Afterward, we reviewed tension pneumothorax and how to recognize it, as well as the effects it has on an injured casualty. We talked about treatment with chest seals when present, but also about the importance of needle decompression of the chest and the sites available to us when performing an NDC.

We also discussed what to do for unsuccessful NDC attempts and recurrent tension pneumothorax symptoms, including the use of finger and/or tube thoracostomies by providers trained and authorized to perform those procedures.

To close out this module, check your learning with the questions below (answers under the image).

# Answers

### Which factors influence TCCC?

- Hostile fire, tactical considerations, wounding patterns, environmental considerations, level of first-responder training and experience, equipment constraints, and the potential for significant delays in evacuation.

### What are the phases of care in TCCC?

- Care Under Fire, Tactical Field Care, and Tactical Evacuation Care.

### What is the most essential treatment task in CUF/Threat?

- Application of a limb tourniquet to control massive bleeding.

### What is every first responder’s role in CUF/Threat?

- Suppress hostile fire and/or establish scene safety, assist in self-aid, and assist in moving casualties, if feasible.

### What does MARCH PAWS stand for?

- Massive bleeding
- Airway
- Respirations (breathing)
- Circulation
- Hypothermia AND head injury
- Pain
- Antibiotics
- Wounds
- Splints

1 DOD Instruction 1322.24. Medical Readiness Training. 16 March 2018. Accessed at https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/132224p.pdf?ver=2018-03-16-140510-410, Change 1 Effective 15 February 2022.

2 www.deployedmedicine.com

3 Eastridge BJ, Mabry RL, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012 Dec;73(6 Suppl 5): S431-7.

4 Butler FK Jr, Hagmann J, Butler EG. Tactical combat casualty care in special operations. Mil Med. 1996 Aug;161 Suppl: 3-16.

5 Tactical Combat Casualty Care Guidelines, 15 December 2021, https://deployedmedicine.com/market/31/content/40

6 Tactical Combat Casualty Care Guidelines, 15 December 2021, https://deployedmedicine.com/market/31/content/40, accessed 14 Nov 21.

7 Tactical Combat Casualty Care Guidelines, 15 December 2021, https://deployedmedicine.com/market/31/content/40,

8 Jacobs LM, McSwain NE Jr, Rotondo MF, Wade D, Fabbri W, Eastman AL, Butler FK Jr, Sinclair J; Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events. Improving survival from active shooter events: the Hartford Consensus. J Trauma Acute Care Surg. 2013 Jun;74(6): 1399-400.

9 Ritenour AE, Baskin TW. Primary blast injury: update on diagnosis and treatment. Crit Care Med. 2008 Jul;36(7 Suppl): S311-7.

10 Tactical Combat Casualty Care Skill Sets by Responder Level, Deployed Medicine website: https://learning-media.allogy.com/api/v1/pdf/63ad6e0e-aff7-497c-a7db-394570021997/contents, accessed 19 Nov 21.

11 Butler FK Jr, Hagmann J, Butler EG. Tactical combat casualty care in special operations. Mil Med. 1996 Aug;161 Suppl: 3-16.

12 Butler FK. Two Decades of Saving Lives on the Battlefield: Tactical Combat Casualty Care Turns 20. Mil Med. 2017 Mar;182(3): e1563-e1568.

13 Kotwal RS, Montgomery HR, Kotwal BM, Champion HR, Butler FK Jr, Mabry RL, Cain JS, Blackbourne LH, Mechler KK, Holcomb JB. Eliminating preventable death on the battlefield. Arch Surg. 2011 Dec;146(12): 1350-8.

14 Kotwal RS, Montgomery HR, Miles EA, Conklin CC, Hall MT, McChrystal SA. Leadership and a casualty response system for eliminating preventable death. J Trauma Acute Care Surg. 2017 Jun;82(6S Suppl 1): S9-S15.

15 Bellamy RF. The causes of death in conventional land warfare: implications for combat casualty care research. Mil Med. 1984 Feb;149(2):55-62.

16 Mabry RL, Holcomb JB, Baker AM, Cloonan CC, Uhorchak JM, Perkins DE, Canfield AJ, Hagmann JH. United States Army Rangers in Somalia: an analysis of combat casualties on an urban battlefield. J Trauma. 2000 Sep;49(3):515-28

17 Bellamy RF. The causes of death in conventional land warfare: implications for combat casualty care research. Mil Med. 1984 Feb;149(2):55-62.

18 Butler FK Jr, Hagmann J, Butler EG. Tactical combat casualty care in special operations. Mil Med. 1996 Aug;161 Suppl: 3-16.

19 Kelly JF, Ritenour AE, McLaughlin DF, Bagg KA, Apodaca AN, Mallak CT, Pearse L, Lawnick MM, Champion HR, Wade CE, Holcomb JB. Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 versus 2006. J Trauma. 2008 Feb;64(2 Suppl): S21-6; discussion S26-7.

20 Holcomb JB, McMullin NR, Pearse L, Caruso J, Wade CE, Oetjen-Gerdes L, Champion HR, Lawnick M, Farr W, Rodriguez S, Butler FK. Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001-2004. Ann Surg. 2007 Jun;245(6): 986-91.

21 Butler FK Jr, Blackbourne LH. Battlefield trauma care then and now: a decade of Tactical Combat Casualty Care. J Trauma Acute Care Surg. 2012 Dec;73(6 Suppl 5): S395-402.

22 Kragh JF Jr, Baer DG, Walters TJ. Extended (16-hour) tourniquet application after combat wounds: a case report and review of the current literature. J Orthop Trauma. 2007 Apr;21(4):274-8.

23 Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009 Jan;249(1):1-7.

24 Gerold KB, et al. The relevance of Tactical Combat Casualty Care (TCCC) guidelines to civilian law enforcement operations. The Tactical Edge. Fall 2009: 52-56.

25 Fike JA, Scalese RJ, Issenberg SB. TCCC Training Baseline Assessment Summary Report. Mobile Technology and Mobile Learning Survey Site Study ID: 20130459. Dec 2018.

26 Butler FK Jr, Hagmann J, Butler EG. Tactical combat casualty care in special operations. Mil Med. 1996 Aug;161 Suppl:3-16.

27 Bellamy RF: How shall we train for combat casualty care? Mil Med 1987; 152: 617-22.

28 Ekblad GS: Training medics for the combat environment of tomorrow. Mil Med 1990; 155: 232-4.

29 Butler FK. Two Decades of Saving Lives on the Battlefield: Tactical Combat Casualty Care Turns 20. Mil Med. 2017 Mar;182(3): e1563-e1568.

30 Butler FK, Blackbourne LH: Battlefield trauma care then and now: a decade of tactical combat casualty care. J Trauma Acute Care Surg. 2012; 73: S395–S402.

31 Deputy Assistant Secretary of Defense Policy Memo. 19 June 2013.

32 https://jts.amedd.army.mil/index.cfm/committees/cotccc/mission, accessed Nov 21.

33 Giebner SD. The Transition to the Committee on Tactical Combat Casualty Care. Wilderness Environ Med. 2017 Jun;28(2S): S18-S24.

34 Assistant Secretary of Defense for Health Affairs. Institutionalization Milestones of Tactical Combat Casualty Care Training, Certification, and Reporting in the Department of Defense. 4 April 2019.

35 Assistant Secretary of Defense for Health Affairs. Department of Defense Joint Trauma System Lifesaving Materiel Policy Memorandum. 17 April 2018.

36 DOD Instruction 1322.24. Medical Readiness Training. 16 March 2018. Accessed at https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/132224p.pdf?ver=2018-03-16-140510-410, 18 Nov 21.

37 Tarpey MJ. Tactical combat casualty care in Operation Iraqi Freedom. US Army Med Dep J 2005; 38–41.

38 Kotwal RS, Montgomery HR, Kotwal BM, Champion HR, Butler FK Jr, Mabry RL, Cain JS, Blackbourne LH, Mechler KK, Holcomb JB. Eliminating preventable death on the battlefield. Arch Surg. 2011 Dec;146(12): 1350-8.

39 Butler FK. Two Decades of Saving Lives on the Battlefield: Tactical Combat Casualty Care Turns 20. Mil Med. 2017 Mar;182(3): e1563-e1568.

40 King DR. Initial Care of the Severely Injured Patient. N Engl J Med. 2019 Feb 21;380(8):763-770.

41 Howard JT, Kotwal RS, Stern CA, Janak JC, Mazuchowski EL, Butler FK, Stockinger ZT, Holcomb BR, Bono RC, Smith DJ. Use of Combat Casualty Care Data to Assess the US Military Trauma System During the Afghanistan and Iraq Conflicts, 2001-2017. JAMA Surg. 2019 Jul 1;154(7):600-608.

42 https://jts.amedd.army.mil/index.cfm/about/vision

43 Hinton HL Jr. Operation Desert Storm: Full Army Medical Capability Not Achieved. GAO/NSIAD-92-175. Washington, DC: United States General Accounting Office; 1992

44 https://jts.amedd.army.mil/index.cfm/about/origins

45 DOD Instruction 6040.47. Joint Trauma System. 14 June 2022. Accessed at https://www.esd.whs.mil/portals/54/documents/dd/issuances/dodi/604047p.pdf.

46 Spott MA, Kurkowski CR, Stockinger ZB. The Joint Trauma System: History in the Making, Military Medicine, Volume 183, Issue supplement 2, September-October 2018: 4–7.

47 https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/604047p.pdf?ver=2018-08-06-124902-047

48 https://jts.amedd.army.mil/assets/docs/JTS-Organizational-Chart.pdf.