TACTICAL COMBAT CASUALTY CARE

The TCCC guidelines are foundational knowledge for austere providers at all levels of training, and as of 2019 TCCC Training is a requirement for all medical providers. Thorough knowledge of current TCCC guidelines will not only help surgical teams understand care provided at point of injury, but will also provide battle-tested options for care that is appropriate in austere environments, even for surgical teams. A thorough understanding of tourniquets, their associated complications, and recommendations for conversion to pressure dressings and removal in the austere environment is fundamental to TCCC and is not common knowledge for providers without prior tactical medical experience. TCCC airway management, pain management, and resuscitation recommendations have been implemented with a high degree of success.

Mass casualty (MASCAL) scenarios are especially challenging in resource-limited environments. A small number of casualties can quickly turn into a MASCAL for the austere team. Mastery of the concepts of TCCC will save lives in this setting.17-23 Principles of dynamic triage must be utilized during all phases of care, including intraoperatively, and not be limited to the initial evaluation.13 Proper triage results in the greatest good for the greatest number. This cannot be overstated. The burden of these decisions is heavy. Redundancy in triage and clinical skills is especially necessary for ARSC teams given that they do not have all the resources of a standard Role 2 and because every member will be task saturated. Realistic, challenging MASCAL and triage scenarios should be trained during pre-deployment in order to work through difficult decisions based on limited resources.

Austere teams should maximize the use of limited resources by restricting surgical interventions to damage control only, particularly when evacuation timelines are short. When evacuation timelines are delayed, more definitive or repeat surgeries may be required. For example, a vascular shunt may temporize arterial injury, but when evacuation is delayed beyond 24 hours, definitive vascular reconstruction or amputation may be indicated. When transferring patients to a host nation facility, the capability for definitive surgical care may be absent or unknown. This highlights the wide and complex spectrum of clinical care in the austere setting and emphasizes the importance of understanding time and distance to the next level of care with a clear knowledge of the transport capability as well as the receiving facility’s capability.

When evacuation is delayed and patients are held by a surgical team after the initial resuscitative care, the surgeon must weigh the risks of definitive surgery against the risks of ischemia and infection. There are currently not enough outcome data available to make firm recommendations for patients being managed more than 72 hours in an austere environment.