Due to the resolute efforts of the Committee on TCCC and the members of the TCCC Working Group over the last 25 years, the advances described in the preceding section made TCCC increasingly prevalent as the standard for battlefield trauma care in the Department of Defense over that time span. USSOCOM mandated TCCC training for its forces in 2005 and, in partnership with the USAISR, established the TCCC Transition Initiative to fast-track TCCC training and equipment to its units. The Navy Bureau of Medicine and Surgery (BUMED)-directed review of TCCC conducted in 2006/2007 found that TCCC was used not only by Special Operations forces, but also by all of the conventional forces in the US military. The Marine Corps likewise directed that TCCC be the standard for battlefield trauma care in 2006. In February 2009, the Army directed that all medical department members get TCCC training as part of their pre-deployment trauma preparation. This widespread adoption of TCCC was noted in other reports

In March of 2009, Dr. Ward Cascells, the Assistant Secretary of Defense for Health Affairs, recommended to the military services that TCCC be used as the standard for training combat medical personnel to manage combat trauma in the tactical pre-hospital environment. In August of 2009, the Defense Health Board, the senior civilian medical advisory board to the Secretary of Defense, recommended that TCCC be taught to all deploying combatants and to all combatant unit medical providers. In 2011 and again in 2014, this recommendation was repeated by Dr. Cascells’ successor, Dr. Jonathan Woodson.

In 2015, Vice Admiral Matt Nathan, the Navy Surgeon General, addressed a major disconnect in TCCC readiness training that had been identified in both Joint Trauma System/US Central Command surveys of prehospital trauma care in Afghanistan – the need to ensure that the medical department officers who supervise combat medical personnel are also trained in TCCC concepts. VADM Nathan’s 2015 directive mandated TCCC training for all active duty and reserve physicians, physician assistants, advanced nurse practitioners, nurse generalists, and Hospital Corpsmen assigned to the Navy Bureau of Medicine and Surgery BUMED. This directive also sought to address another major issue in TCCC training – the lack of a standardized TCCC curriculum. VADM Nathan’s guidance was that all BUMED TCCC training courses will use the curriculum developed by the CoTCCC. The need to use the JTS/CoTCCC curriculum as the standard in training TCCC has been identified in a number of recent reports.

From the warfighting Combatant Commander perspective, General James Mattis, when he was the Commander of the U.S. Central Command in 2013, wrote a letter to the Service Chiefs of Staff in which he noted the unprecedented success in eliminating preventable death in combat casualties achieved by the Ranger Casualty Response System through training all unit members in TCCC. He urged each of them to be briefed on TCCC and the importance of this lifesaving training. General Joseph Votel went a step further in his letter to the Service Chiefs of 6 November 2017. General Votel, a former 75th Ranger Regiment Commander, again emphasized the lives that could be saved with TCCC training and equipment and stated that: “I am instituting a theatre TCCC training requirement, to be completed with 180 days of deployment.”

The narrative above shows how many different directives have been issued on battlefield trauma care by the various services and combatant commands. On 16 March 2018, the Department of Defense issued an instruction that clarified the issue for the U.S. Military. This directive reads in part: “It is DoD policy that….TCCC is the DoD standard of care for first responders (medical and non-medical) and the All Service Member TCCC course replaces Service trauma skills currently taught in first aid and self-aid buddy care courses.” The directive also requires that: “All Service members receive role based TCCC training and certification in accordance with the skill level (i.e., All Service Members, Combat Lifesaver, Combat Medic/Corpsmen, and Combat Paramedic/Provider) outlined by the Joint Trauma System, the DoD’s Center of Excellence for trauma as designated in DoD Instruction (DoDI) 6040.47.”

Work remains to be done to make this directive a reality, however. A letter sent to now-Secretary of Defense Mattis sent on 4 December 2018 by 17 members of the U.S. House of Representatives states in part: “We understand that Tactical Combat Casualty Care (TCCC) has achieved unprecedented success in decreasing preventable combat deaths in military units that have received accurate TCCC training, but we are disturbed by reports highlighting inadequate training.”

Clearly, the Department of Defense Instruction does not immediately accomplish the desired intent of high-quality TCCC for all. What is needed to make that happen is for line combat leaders to make this training a priority, as the 75th Ranger Regiment did, and to ensure that DODI 1322.24 is well-executed within their organizations. A model for senior leader attention to battlefield trauma care was the all-Navy “OPNAV” instruction in which the Chief of Naval Operations directed how TCCC training should be implemented for all Naval forces.

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