Background on TCCC

#### Background

For those who are wounded on the battlefield, the most critical phase of care is the period between the time they are injured and the time that they arrive at a medical treatment facility (MTF) capable of providing the surgical care they need. Almost 90% of combatants who die from their wounds do so before they arrive at an MTF. If a casualty survives long enough to reach the care of a combat surgeon, the likelihood is very high that he or she will survive. This fact highlights the importance of the battlefield trauma care provided by combat medics, corpsmen, and pararescuemen (PJs) as well as by non-medical unit members in improving the survival of the casualties of war.

Battlefield trauma care 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 may be required to provide care while under hostile fire, often working in the dark, with multiple casualties and with limited equipment. They must also often contend with prolonged evacuation times as well as the need for tactical maneuver superimposed upon 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.

The above considerations notwithstanding, at the onset of the American initiation of hostilities in Afghanistan in 2001 following the attacks of 9/11, most U.S. combat medical personnel were being trained using the following civilian-based principles of trauma care:

- Care was to be rendered with no structured consideration of the evolving tactical situation
- No use of tourniquets to control extremity hemorrhage
- External hemorrhage was managed with prolonged direct pressure, precluding the medic from attending to the other injuries that the casualty may have sustained or from rendering care to other casualties
- There was no use of hemostatic dressings
- Two large-bore IVs were to be started on all patients with significant trauma
- Hypovolemic shock was treated with large-volume crystalloid fluid resuscitation
- There were 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 was accomplished with endotracheal intubation
- There were no specific techniques or equipment to prevent hypothermia and secondary coagulopathy in combat casualties
- Management of pain in combat casualties was with intramuscular (IM) morphine – a battlefield analgesic that dated back to the Civil War
- There was no intraosseous access capability
- The was no use of prehospital electronic monitoring used by ground forces
- There was no use of effective non-parenteral analgesic medications
- There were no prehospital antibiotics
- There was no delineation of which casualties might benefit most from supplemental oxygen during tactical evacuation
- Spinal precautions were applied broadly to casualties with significant trauma, without consideration of tactical concerns or mechanism of injury
- There was no guidance on how to manage wounded hostile force prisoners

Reconsideration of trauma care guidelines for tactical settings had not been accomplished by the U.S. military as of 1992, even though the need had long been recognized. Tactical Combat Casualty Care is a set of evidence-based, best-practice prehospital trauma care guidelines that was developed specifically for use on the battlefield. Following the publication of the original TCCC paper in 1996, prehospital trauma care in the US military has undergone an unprecedented transformation.

References

Baker MS. Advanced trauma life support: Is it acceptable stand-alone training for military medicine? Mil Med. 1994;159(9):581–590.

Bellamy RF. How shall we train for combat casualty care? Mil Med. 1987;152(12):617–621.

Butler FK, Blackbourne LH. Battlefield Trauma Care Then and Now: A Decade of Tactical Combat Casualty Care. J Trauma Acute Care Surg. 2012;73(6)( Suppl 5):S395-402. doi: 10.1097/TA.0b013e3182754850.

Butler FK, Hagmann J, Butler EG. Tactical Combat Casualty Care in Special Operations. Mil Med. 1996;161(suppl):1–16.

Heiskell LE, Carmona RH: Tactical emergency medical services: An emerging subspecialty in emergency medicine. Ann Emerg Med. 1994;23:778-785.

#### Tourniquets Reconsidered and the Need for TCCC

#### Beginning of TCCC

TCCC began as the result of a Naval Special Warfare biomedical research effort that was undertaken after a striking paradox in battlefield trauma care was identified. Extremity hemorrhage had been reported to be a leading cause of preventable death on the battlefield during the Vietnam conflict. However, in 1992, US military combat medics, corpsmen, and PJs were not being taught to use a readily available and highly effective treatment for extremity bleeding – a tourniquet, despite the fact that tourniquets had long been routinely used by orthopedic surgeons performing extremity surgery. The realization that such a major opportunity to improve had not been acted upon prompted a systematic review of all aspects of battlefield trauma care. The TCCC 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.

The original TCCC guidelines provided combat medics and corpsmen with trauma management strategies that combined good medicine with good small-unit tactics. TCCC recognizes that there are three goals for trauma care in the tactical environment: (1) treat the casualty; (2) prevent additional casualties; and (3) complete the mission.

After a 4-year research effort, the original TCCC paper proposed some (at the time) radical changes to battlefield trauma care, including:

- A three-phase approach to tactical trauma care to ensure that the care being rendered is tailored to the evolving tactical environment.
- The aggressive use of tourniquets to control life-threatening extremity bleeding
- Tactically appropriate fluid resuscitation
- Improved battlefield analgesia (IV vs. IM morphine)
- Battlefield antibiotics
- Nasopharyngeal airways as first-line airway devices for unconscious casualties without airway obstruction.
- Surgical airways for maxillofacial trauma with airway obstruction
- Aggressive diagnosis and needle decompression of tension pneumothorax
- Combat medic input into the TCCC guidelines
- Scenario-based TCCC training
- A standing committee of experts in tactical medicine to monitor the success and shortcomings of the original TCCC Guidelines; consider new evidence that becomes available in the field of prehospital trauma care; and propose modifications to TCCC as indicated.

As the name implies, TCCC is used when casualties are sustained during combat missions. Prehospital trauma care in the military is most commonly provided by enlisted combat medical personnel: medics in the Army and in the Navy SEAL community, corpsmen in the Navy and Marine Corps, and both medics and pararescuemen (“PJs”) in the Air Force, although physicians and physician assistants may provide prehospital care to the wounded in some situations.

TCCC is divided into three phases: Care Under Fire/Threat, Tactical Field Care, and Tactical Evacuation Care. In the Care Under Fire phase, combat medical personnel and their units are under effective hostile fire, and the care they can provide to the wounded is very limited. In the Tactical Field Care phase, medical personnel and their casualties are no longer under effective hostile fire, and more extensive care can be provided. Finally, in the Tactical Evacuation phase, casualties are transported to a medical facility by an aircraft, ground vehicle or boat, and there is an opportunity to provide additional medical personnel and equipment to elevate the level of care rendered.

References

Bellamy RF. How shall we train for combat casualty care? Mil Med. 1987;152(12):617–621.

Butler FK: Two Decades of Saving Lives on the Battlefield: Tactical Combat Casualty Care Turns 20. Military Medicine 2017;182:e1563-e1568

Butler FK, Hagmann J, Butler EG. Tactical Combat Casualty Care in Special Operations. Mil Med. 1996;161(suppl):1–16.

Butler FK. Tactical Combat Casualty Care – Beginnings. Wilderness Environ Med. 2017 Jun;28(suppl 2):S12-S17.

Maughon JS. An inquiry into the nature of wounds resulting in killed in action in Vietnam. Mil Med. 1970;135:8-13.

Butler FK. Military history of increasing survival: The US military experience with tourniquets and hemostatic dressings in the Afghanistan and Iraq conflicts. Bull Am Coll Surg. 2015 Sep;100(1 Suppl):60-64.

#### TCCC in the Pre-War Years

#### TCCC prior to Afghanistan and Iraq

The first TCCC course was taught in 1996 in the Undersea Medical Officer course sponsored by the Navy Bureau of Medicine and Surgery (BUMED). Shortly thereafter, this training was mandated for all SEAL corpsmen.

The incorporation of the TCCC guidelines into the Prehospital Trauma Life Support (PHTLS) textbook was an important milestone in the evolution of TCCC. The fourth edition of this manual, published in 1999, contained a chapter on military medicine for the first time, and TCCC was included as part of that chapter. The recommendations contained in the PHTLS textbook carry the endorsement of the American College of Surgeons Committee on Trauma and the National Association of Emergency Medical Technicians. TCCC is the only set of battlefield trauma care guidelines ever to have received the endorsements of these internationally respected trauma care organizations as well as that of the US Department of Defense (DoD).

During the peace interval that existed for the United States from 1996 to 2001, adoption of TCCC by the U.S. military proceeded slowly outside of the Special Operations Community. That all changed when the attacks on the U.S. by Al Qaeda resulted in a U.S. military response in Afghanistan, followed in 2003 by the invasion of Iraq. The first published report of TCCC’s success in combat was that by Tarpey in 2005, but others soon followed, and TCCC gradually gained acceptance throughout the US military.

References

Allen RC, McAtee JM. Pararescue medications and procedures manual. Hurlburt Field, FL: Air Force Special Operations Command; 1999.

Butler FK, Holcomb JB, Giebner SD, McSwain NE, Bagian J. Tactical Combat Casualty Care 2007: Evolving concepts and battlefield experience. Mil Med 2007;172(suppl):1–19.

Butler FK. Tactical medicine training for SEAL mission commanders. Mil Med. 2001;166(7):625–631.

DeLorenzo, RA. Medic for the millennium: The US Army 91W healthcare specialist. Mil Med. 2001;166(8):685–688.

Gresham JD: Giving Back, Again: Master Sergeant Luis Rodriguez and the Tactical Combat Casualty Care Course. The Year in Military Medicine. 2005

Holcomb, JB. The 2004 Fitts Lecture: current perspective on combat casualty care. J Trauma. 2005;59(4):990–1002.

Malish RG. The medical preparation of a special forces company for pilot recovery. Mil Med. 1999;164(12):881–884.

McSwain NE, Frame S, Paturas Jl, Eds: Prehospital Trauma Life Support Manual. Akron, Mosby, Fourth Edition; 1999

Pappas CG. The Ranger Medic. Mil Med. 2001;166(5):394–400.

Richards TR. Commander, Naval Special Warfare Command letter. 1500 Ser 04/0341; 9 April 1997.

Tarpey M. Tactical Combat Casualty Care in Operation Iraqi Freedom. US Army Med Dept J. 2005;April–June:38–41.

#### Changing the Culture in Battlefield Trauma Care

The reports discussed above, however, were not in and of themselves enough to effect changes that were needed in battlefield trauma care. Strong leadership by combat unit commanders acting on the advice of well-informed operational medical leaders was an essential element in this transformation.

Adoption of TCCC required a move away from longstanding and firmly entrenched approaches to battlefield trauma care. How did this transformation in battlefield trauma care in the U.S. military come about? As noted previously, the Navy SEAL teams and the 75th Ranger Regiment began training all combatants in TCCC prior to the start of the conflicts in Afghanistan and Iraq. The Army Special Missions Unit and the Air Force Pararescue community also implemented TCCC from in the 1997/1998 time frame and quickly adopted the practice of teaching TCCC to every combatant so that the most critical life-saving interventions, like tourniquets, could be accomplished by every one of their unit members.

The transformation of TCCC use from the few early adopters to being used throughout the DoD resulted from a specific sequence of events that has been well documented but is not widely known. When US forces invaded Afghanistan in 2001, there was no Joint Trauma System in place and no mechanism for the systematic review of combat casualty care outcomes in the US military to look for opportunities to improve care. Specifically, from 2001 to 2004, there was no DoD focus on the causes of preventable deaths among US fatalities and how those deaths might have been prevented. TCCC during this period was used only by those few military units that had adopted these new concepts before 2001. How did this culture change in the U.S. Military finally come about?

The first and most fundamental requirement for changing the culture in battlefield trauma care was to provide a higher quality set of recommendations. There were several aspects of the TCCC development process that enabled these improved recommendations. 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 regimen. Next, as opposed to simply adopting a civilian-oriented standard of care, the actual conditions that combat medical personnel 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 heeded throughout the TCCC development process, thereby obtaining a reality check on proposed recommendations by those who would be responsible for implementing them.

The second step in changing the culture in battlefield trauma care, and the one that was responsible for the initial spread of TCCC beyond the few early adopters, was the first preventable death review of US fatalities from Iraq and Afghanistan. In 2004, the US Special Operations Command (USSOCOM) had two critically important questions that needed to be answered: 1) what, specifically, were the causes of death in Special Operations forces who had died as a result of combat wounds in those conflicts; and 2) what, if anything, might have been done to prevent those deaths? One might reasonably assume that the Department of Defense had always performed preventable death reviews on its combat fatalities, but, as of 2004, there was no formal process in place to review American combat deaths and to use that information to save the lives of future casualties. USSOCOM called upon COL John Holcomb, then the Commander of the US Army Institute of Surgical Research, 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 such as a tourniquet. This study sent a clear signal that TCCC training and equipment was 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 event that led to the widespread adoption of TCCC concepts was a US Central Command 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, then-Colonel Doug Robb. Although the services have the primary responsibility for training and equipping combatants, this mandate from Central Command forced supervising medical officers throughout the services to rethink their many years of medical training that had consistently taught that them that the use of extremity tourniquets was an ill-advised idea.

The fourth landmark event in changing the culture on battlefield trauma care also resulted from a collaboration between USSOCOM and USAISR. After the documentation of preventable deaths in the Holcomb study, the leadership of USSOCOM supported and funded 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 training and equipment to deploying Special Operations units, but also collected feedback from medics, corpsmen, and PJs when these units returned from combat operations. In addition, this program provided early documentation of the success of TCCC interventions. The USAISR preventable death project, which had produced usable information on Special Operations fatalities by early 2005, even though it was not published until several years later, and the early results of the TCCC Transition initiative, prompted the U.S. Special Operations Command to mandate in March of 2005 that TCCC principles be used in caring for combat casualties and that all U.S. Special Operations Command component commands begin training and equipping their forces in TCCC.

The fifth key step that helped to change the culture of battlefield trauma care in the U.S. military was the documentation of the lifesaving impact of extremity tourniquet use. It is often difficult to identify with precision which elements of TCCC are responsible for lives saved, but tourniquets are an exception. The work of COL John Kragh, an orthopedic surgeon working at the Ibn Sina hospital in Baghdad, documented that 31 lives were saved with tourniquets at his facility in one 6-month period. 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 likely been saved with tourniquets. This extraordinary reduction in preventable death was obtained without loss of limbs due to tourniquet ischemia. COL Kragh’s work irrefutably confirmed the lifesaving benefit of one what was perhaps the single most controversial aspect of TCCC.

The sixth event was the information that became available in 2012 that documented the difference between the preventable death rates in units using TCCC in contrast to units that were not necessarily using TCCC. After ten years of combat operations in Iraq and Afghanistan by the 75th Ranger Regiment, Kotwal and his colleagues reported only one potentially preventable death among 32 combat fatalities (out of 419 casualties) sustained by the 75th Rangers, and that death occurred in the hospital, not the prehospital, setting. This finding stands in stark contrast to the15% to 28% incidence of potentially preventable deaths reported in other studies of U.S. casualties in these conflicts. Considering the prehospital phase of care only, potentially preventable deaths among fatalities in the 75th Rangers was zero as compared to 24% in the study by Eastridge et al. This remarkable disparity in potentially preventable deaths between early adopters of TCCC and the rest of the US military was not widely known until the Kotwal and Eastridge studies were published in 2011 and 2012, respectively. These observed differences in potentially preventable deaths may be due in part to differences in the methodology of determining which deaths are considered potentially preventable or differences between the casualty cohorts reported. Those points notwithstanding, there is little to no disagreement at present that the interventions pioneered by TCCC produced a marked reduction in preventable deaths in the prehospital phase of combat casualty care – the phase of care during which combat fatalities are most likely to occur.

The seventh key step in changing the culture of the US military to accept TCCC was effective strategic messaging. The success of the TCCC Transition Initiative, COL Kragh’s findings on tourniquets, and the decreased incidence of preventable deaths in units that were early TCCC adopters were presented at military medical conferences and in the published medical and lay literature. This broad coverage both increased awareness among combat medical personnel and their physician/physician assistant supervisors of the success of TCCC in reducing preventable deaths and provided unit medical officers with published evidence that they could present to their unit commanders when seeking to implement TCCC in their units.

The TCCC experience has made it abundantly clear that a necessary component of advances in battlefield trauma care is combat line commander attention and advocacy. Evidence alone is often not sufficient to drive advances in trauma care. Multiple challenges inherent in effecting change in battlefield trauma care in the U.S. military have been identified.

The divided lines of authority and distributed responsibilities in the military structure make it difficult to develop and implement such advances throughout the Department of Defense. Butler, Smith, and Carmona described the potential barriers to change in this way.

“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 US Military has four armed services, six Geographic Combatant Commands, the US Special Operations Command and the US 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 Staff, and Service leadership levels, the span of responsibilities is immense and the ability of leaders at this level to focus on and mandate aspects specific aspects of trauma care is limited. Therefore, to date, when change is effected in battlefield trauma care, it typically first occurs at lower levels in the military chain of command and benefits only those individuals in that part of the organization – until it eventually becomes more widespread.

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 wasn’t a physician, but his leadership paved the way for saving many hundreds of lives among US combat casualties.

A similar occurrence took place in the 75th Ranger Regiment. In 1997, the regiment’s commander, then-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. 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 if needed, and so every Ranger received training in TCCC.

Likewise, General Doug Brown and Vice Admiral Eric Olson at the US Special Operations Command mandated TCCC at a time when it was not the standard of care for prehospital trauma care, either in the US military or in the civilian sector. General John Abizaid at the US Central Command did much the same thing in requiring the use of tourniquets and hemostatic dressings in Iraq and Afghanistan at a time when conventional wisdom dictated otherwise. It is apparent from this discussion that new evidence alone does not drive advances in trauma care – in either the civilian sector or the military. Leaders do that.

It should also be noted, both in the military and in the civilian sector, medical decision makers at senior levels are often not the subject matter experts. As former US Surgeon General Richard Carmona pointed out during the Hartford Consensus IV meeting, 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 above – 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 the time and resources required implement these changes.

References

Beekley AC, Starnes BW, Sebesta JA. Lessons learned from modern military surgery. Surg Clin N Am. 2007;87(1):157–184.

Berwick D, Downey A, Cornett E, eds: A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. National Academies of Science Engineering and Medicine Report. National Academies Press, 2016.

Bottoms M. Tactical Combat Casualty Care—Saving lives on the battlefield. Tip of the Spear (Command Publication of the US Special Operations Command). 2006;June:34–35.

Brown BD. Special Operations combat medic critical task list. Commander, US Special Operations Command letter, 9 March 2005.

Butler FK. Two decades of saving lives on the battlefield: Tactical Combat Casualty Care turns 20. Mil Med. 2017;182(3):e1563-e1568.

Butler FK. Leadership Lessons Learned in Tactical Combat Casualty Care. J Trauma Acute Care Surg. 2017 Jun;82(6S suppl 1):S16-S25.

Butler FK. Tactical Combat Casualty Care – Beginnings. Wilderness Environ Med. 2017 Jun;28(suppl 2):S12-S17.

Butler FK, Smith DJ, Carmona RH. Implementing and preserving advances in combat casualty care from Iraq and Afghanistan throughout the US military. J Trauma Acute Care Surg. 2015 Aug;79(2):321-326.

Butler FK, Holcomb JB. The Tactical Combat Casualty Care transition initiative. US Army Med Dept J. 2005;April–June:33-37.

Eastridge BJ, Mabry RL, Seguin P, et al. Death on the Battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6)(suppl 5):S431-S437.

Dickey N, Jenkins D: Combat Trauma Lessons Learned from Military Operations of 2001-2013. Defense Health Board Report. 9 March 2015

Holcomb JB, McMullen NR, Pearse L, et al. Causes of death in Special Operations forces in the global war on terrorism: 2001-2004. Ann Surg. 2007;245(6):986–991.

Holcomb JB, Stansbury LG, Champion HR, Wade C, Bellamy RF. Understanding combat casualty care statistics. J Trauma. 2006;60(2):397–401.

Jacobs LM and the Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Shooting Events. The Hartford Consensus IV: A call for increased national resilience. Conn Med J. 2016;80:239-244.

Kelly JF, Ritenhour AE, McLaughlin DF, et al. Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003 2004 versus 2006. J Trauma. 2008; 64(2)(suppl):S21-S27.

Kotwal R, Montgomery H, Conklin C, et al: Leadership and a casualty response system for eliminating preventable death. J Trauma Acute Care Surg. 2017 Jun;82(6S suppl 1):S9-S15.

Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating preventable death on the battlefield. Arch Surg. 2011;146(12):1350-1358.

Kragh J, Walters T, Westmoreland T, Miller R, Mabry RL, Kotwal RS, Ritter BA, Hodge DC, Greydanus DJ, Cain JS, Parsons DL, Edgar EP, Harcke T, Baer DG, Dubick MA, Blackbourne LH, Montgomery HR, Holcomb JB, Butler FK. Tragedy into drama: an American history of tourniquet use in the current war. J Spec Oper Med. 2013;13:5-25.

Kragh JF, Walters TJ, Baer, DJ, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009;249(1):1–7.

Kragh JF, Walters TJ, Baer DG, et al. Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma. 2008; 64(2)(suppl):S38–S49.

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U.S. Central Command Message: Tourniquets and Hemostatic Dressings. Date/Time Group 061715Z January 2005 .

U.S. Special Operations Command message: Tactical Combat Casualty Care Training and Equipment. Date/Time Group 222016Z March 05; 2005

#### Battlefield Trauma Care in 2022

Published evidence and battlefield experience accumulated over the 25 years since the original TCCC paper was published have resulted in all services in the U.S. Military and many allied nations using TCCC concepts to care for their combat wounded. All U.S. combat medics, corpsmen, and pararescuemen are now taught battlefield trauma care techniques based on the TCCC Guidelines. Military units that have trained all their members, including both medical and non-medical personnel, in TCCC have documented the lowest incidence of preventable deaths among their casualties in the history of modern warfare. TCCC-based prehospital trauma training is now widespread in the US civilian sector as well.

TCCC guidelines are reviewed on an ongoing basis and updated as needed by the CoTCCC. Proposed changes to the Guidelines must be approved by a 75% majority of the CoTCCC to be accepted. Changes recommended by the CoTCCC are then forwarded to the Director of the Joint Trauma System for final approval. Once approved, updated versions of the TCCC Guidelines are posted on the Joint Trauma System website as well as the websites of the Defense Health Agency (“Deployed Medicine”), the National Association of Emergency Medical Technicians (NAEMT), the Journal of Special Operations Medicine, and the Special Operations Medical Association. TCCC-based training now provided to all U.S. combat medical personnel includes:

- Phased care in the tactical environment to ensure that good medicine is combined with good small-unit tactics. The three defined phases of care are:
  - Care Under Fire
  - Tactical Field Care
  - Tactical Evacuation (TACEVAC) Care
- Casualty and medic actions during the Care Under Fire phase that focus on gaining and maintaining the tactical advantage, with application of limb tourniquets, when needed, the only medical care recommended for this phase of care.
- The most thorough guidelines available to optimize the use of limb tourniquets, including the use of a second tourniquet when needed to control bleeding; elimination of the distal pulse as a secondary goal for tourniquet application; and the recommendation to attempt conversion from a tourniquet to other methods of bleeding control if the casualty has not yet arrived at a definitive care facility after two hours of tourniquet time.
- The use of hemostatic dressings to control life-threatening hemorrhage from external bleeding at sites that are not amenable to tourniquet use.
- The use of tranexamic acid to help prevent death from non-compressible and junctional hemorrhage as well as moderate/severe traumatic brain injury (TBI).
- The use of junctional tourniquets to help prevent death from junctional hemorrhage.
- The hemostatic adjunct XStat as another option for controlling junctional hemorrhage from wounds with narrow wound tracts.
- Use of the ITClamp to help gain control of external bleeding, especially in casualties with severe bleeding from head and neck trauma.
- Circumferential pelvic binding devices to help reduce the life-threatening internal bleeding that may accompany pelvic fractures.
- The use of nasopharyngeal airways to maintain a patent airway when there is no airway obstruction from direct maxillofacial or neck trauma.
- Initial management of the airway in maxillofacial trauma by having the casualty sit up and lean forward, if possible, thus allowing blood to simply drain out of the oropharynx, clearing the airway.
- Surgical airways for maxillofacial or neck trauma when airway compromise is present, and the sit-up-and-lean-forward position is not feasible or not successful.
- Aggressive needle thoracostomy with a 10 or a 14-gauge, 3.25-inch needle for suspected tension pneumothorax.
- A different approach to spinal precautions – they are not emphasized for casualties with penetrating trauma only, but are still recommended, if tactically feasible, when blunt trauma is present.
- Intravenous (IV) or intraosseous (IO) access only when required for medications or fluid resuscitation.
- The preferential use of a saline lock for IV access as opposed to an IV catheter running fluids at a maintenance (“keep the vein open” or KVO) rate.
- The use of intraosseous devices when vascular access is needed but difficult to obtain.
- Resuscitation of casualties in shock with whole blood or balanced blood components as soon as this becomes logistically feasible in the continuum of care.
- More aggressive fluid resuscitation and supplemental oxygen as needed to avoid hypotension and hypoxia in casualties with traumatic brain injury (TBI).
- The TCCC “Triple-Option Analgesia” plan to provide titrated, faster, safer, and more efficacious battlefield analgesia, using oral analgesics when feasible and ketamine instead of opioids when the casualty is in or at risk of hemorrhagic shock or respiratory distress.
- Ondansetron to control the nausea and vomiting that may be associated with either pain from battlefield trauma or the analgesic medications used to treat it.
- Prevention of hypothermia and secondary coagulopathy through the use of the best available methods to prevent heat loss while in the prehospital phase of care.
- The use of fluoroquinolones and ertapenem on the battlefield to reduce preventable deaths and morbidity from wound infections.
- Combat scenario-based trauma training, emphasizing that trauma care on the battlefield must be consistent with good small-unit tactics.
- Identification of casualties likely to derive the most benefit from supplemental oxygen during TACEVAC.
- Strategies for management of wounded hostile combatants.
- Combat evacuation “Rules of Thumb” and the use of specific injury patterns to help determine casualty evacuation priorities.

References

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Butler FK Jr, Holcomb JB, Shackelford S, et al: Management of Suspected Tension Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 17-02. J Spec Oper Med 2018;18:19-35.

Butler FK: Introduction to TCCC Changes Summary 6 May 2021. J Spec Oper Med 2021;21:107

Butler FK. Two decades of saving lives on the battlefield: Tactical Combat Casualty Care turns 20. Mil Med. 2017;182(3):e1563-e1568.

Butler FK, Blackbourne LH, Gross KR. The Combat Medic Aid Bag: 2025.

CoTCCC top ten recommended battlefield trauma care research, development, and evaluation priorities for 2015; J Spec Oper Med. 2015;15(4):7-19.

Butler FK. Tactical combat casualty care: update 2009. J Trauma. 2010;69(suppl):S10–S13.

Deaton T, Auten J, Betzhold R, et al: Fluid Resuscitation in Tactical Combat Casualty Care: TCCC Guidelines Change 21-01. J Spec Oper Med 2021;21: 126-137

Drew B, Auten JD, Cap AP, et al: The Use of Tranexamic Acid in Tactical Combat Casualty Care: TCCC Guidelines Change 20-02. J Spec Oper Med 2020;20:36-43

Drew B, Montgomery HR, Butler FK: Tactical Combat Casualty Care (TCCC) Guidelines for Medical Personnel: 05 November 2020. J Spec Oper Med 2020;20:144-151

Grissom CK, Weaver LK, Clemmer TP, Morris AH. Theoretical advantage of oxygen treatment for combat casualties during medical evacuation at high altitude. J Trauma 2006;61:461–467.

Montgomery HR, Drew BG, Butler FK: Summary of Recent Changes to the TCCC Guidelines: 14 April 2021. J Spec Oper Med 2021;21:107-108

Montgomery HR, Drew BG: Tactical Combat Casualty Care (TCCC) Update. J Spec Oper Med 2020;20:152-153

Onifer D, McKee J, Faudree L, et al: Management of hemorrhage form craniomaxillofacial injuries and penetrating neck injury in Tactical Combat Casualty Care: iTClamp mechanical wound closure device TCCC Guidelines proposed change 19-04 06 June 2019. J Spec Oper Med 2019;19:31-44

Onifer D, Butler F, Gross K, et al: Replacement of promethazine with ondansetron for treatment of opioid and trauma-related nausea and vomiting in tactical combat casualty care. J Spec Oper Med 2015;15:17-24

Riesberg J, Gurney J, Moore M: The Management of Abdominal Evisceration in Tactical Combat Casualty Care. TCCC Guideline Change 21-02. J Spec Oper Med – In Press

Sims K, Montgomery H, Dituro P, et al: Management of external hemorrhage in Tactical Combat Casualty Care: the adjunctive use of XStat™ compressed hemostatic sponges: TCCC Guidelines change 15-03. J Spec Oper Med 2016;16:19-28

#### TCCC Use in the U.S. Military – 2022

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.

References

Blackbourne LH, Baer DG, Eastridge BJ, et al. Military medical revolution: military trauma system. J Trauma Acute Care Surg. 2012;73(6)(suppl 5):S388 S394. doi:10.1097/TA.0b013e31827548df.

Brown BD. Special Operations combat medic critical task list. Commander, US Special Operations Command letter, 9 March 2005.

Bureau of Medicine and Surgery (Navy Surgeon General) Message 111622Z: Tactical Combat Casualty Care training, December 2006.

Butler FK, Blackbourne LH. Battlefield Trauma Care Then and Now: A Decade of Tactical Combat Casualty Care. J Trauma Acute Care Surg. 2012;73(6)( Suppl 5):S395-402.

Butler FK. Two decades of saving lives on the battlefield: Tactical Combat Casualty Care turns 20. Mil Med. 2017;182(3):e1563-e1568.

Butler FK. Leadership Lessons Learned in Tactical Combat Casualty Care. J Trauma Acute Care Surg. 2017 Jun;82(6S suppl 1):S16-S25.

Butler FK, Smith DJ, Carmona RH. Implementing and preserving advances in combat casualty care from Iraq and Afghanistan throughout the US military. J Trauma Acute Care Surg. 2015 Aug;79(2):321-326.

Butler FK, Holcomb JB, Giebner SD, McSwain NE, Bagian J. Tactical Combat Casualty Care 2007: Evolving concepts and battlefield experience. Mil Med 2007;172(suppl):1–19.

Butler FK, Holcomb JB. The Tactical Combat Casualty Care transition initiative. US Army Med Dept J. 2005;April–June:33-37.

Casscells W. Tactical Combat Casualty Care. Assistant Secretary of Defense for Health Affairs memorandum, 4 March 2009.

DOD Instruction 1322.24 – Medical Readiness Training (MRT). March 16, 2018

Eastridge BJ, Mabry RL, Seguin P, et al. Death on the Battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6)(suppl 5):S431-S437.

Goforth C, Antico D: TCCC Standardization the time is now. J Spec Oper Med. 2016;16:53-56.

Gross KR. Establishing a DoD Standard for TCCC Training: Joint Trauma

System. White paper to the US Military Services Surgeons General. 11 September 2015. Available at https://www.jsomonline.org/TCCC/06%20TCCC%20Reference%20Documents/JTS%20White%20Paper%20TCCC%20Training%20150910%20v12.pdf. Accessed March 23, 2018.

Holcomb JB, Wilensky G. Tactical Combat Casualty Care and Minimizing Preventable Fatalities in Combat. Defense Health Board memorandum dated 6 August 2009. Available at https://health.mil/About-MHS/Defense-Health-Agency/Special-Staff/Defense-Health-Board/Reports. Accessed March 21,2018.

Holcomb, JB. The 2004 Fitts Lecture: current perspective on combat casualty care. J Trauma. 2005;59(4):990–1002.

Hostage GM. USSOCOM visit to the Pararescue medical course at Kirtland AFB September 2005. Air Force Education and Training Command letter, 8 September 2005.

Kiley KC. Operational Needs Statement for Medical Simulation Training Centers for Combat Lifesavers and Tactical Combat Casualty Care Training. Army Surgeon General letter DASG-ZA, 1 September 2005.

Kotwal RS, Butler FK, Edgar EP, Shackelford SA, Bennett DR, Bailey JA. Saving lives on the battlefield: a joint trauma system review of prehospital trauma care in combined joint operating area Y Afghanistan (CJOA-A) executive summary. J Spec Oper Med. 2013;13(1):77Y80.

Mattis J: Letter to the Chiefs of Staff of the U.S. Armed Services. U.S. Central Command letter dated 18 January 2013

Nathan ML. BUMEDINST 1510.25A Navy Medicine Tactical Combat Casualty Care Program. Available at http://www.med.navy.mil/directives/ExternalDirectives/1510.25A.pdf. Accessed March 21, 2018.

OPNAV INSTRUCTION 1500.86: Tactical Combat Casualty Care Training. 12 April 2021

Sauer SW, Robinson JB, Smith MP, et al. Saving Lives on the Battlefield (Part II) - One Year Later. A Joint Theater Trauma System & Joint Trauma System Review of Pre-Hospital Trauma Care in Combined Joint Operating Area Y Afghanistan (CJOA-A). USCENTCOM Report. 2014.

US Marine Corps Message 02004Z: Tactical Combat Casualty Care (TCCC) and Combat Lifesaver (CLS) Fundamentals, Philosophies, and Guidance, August

U.S. Army All Army Activities Message 0902031521Z: Mandatory predeployment trauma training for Army medical department personnel, 3 February 2009.

US Coast Guard Message 221752Z: Tactical Medical Response Program, November 2006.

U.S. House of Representatives letter dated 4 December 2018.

U.S. Special Operations Command message: Tactical Combat Casualty Care

Training and Equipment. Date/Time Group 222016Z March 05; 2005

Votel J: Letter to the Chiefs of Staff of the U.S. Armed Services. U.S. Central Command letter dated 6 Nov 2017

Woodson J. Tactical Combat Casualty Care. Assistant Secretary of Defense for Health Affairs Memorandum. 23 August 2011.

Woodson J. Tactical Combat Casualty Care for deploying personnel. Assistant Secretary of Defense for Health Affairs Memorandum. 14 February 2014.

#### 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 US has just had the longest period of continuous armed conflict in its history create a unique opportunity to study and improve battlefield trauma care. Over two decades of caring for combat casualties, many advances have been incorporated into TCCC as new evidence, new technology, and ongoing battlefield experience have accumulated. Due to the numerous reports noted above that have highlighted the success of TCCC, is now used well beyond the confines of the U,S. military.

#### TCCC in Militaries Around the Globe

TCCC has now been implemented by many coalition partner nations, and has been recommended as the standard of care for combat first-aid training in member nations by the America, Britain, Canada, Australia, New Zealand Armies’ Program.) Canada was one of the earliest international adopters of TCCC. Savage and her colleagues noted that, although the Canadian military experienced increasingly severe injuries during the current conflicts, the Canadian Forces experienced the highest casualty survival rate in that country’s history.” They further reported, “Though this success is multifactorial, the determination and resolve of Canadian Forces 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 224 in 2011.

In 2021, Leeflang and Woets noted in an article from the Netherlands that TCCC is now the “the international standard of care throughout western militaries and is responsible for saving thousands of lives in Afghanistan and Iraq through training and equipping every member of the military with personal medical kits. TCCC is also now used by other government agencies, law enforcement, fire organizations and most allied militaries with the highest medical advisory body in NATO (COMEDS) stating in 2018 that all prehospital care should follow the TCCC principles.” Other past and recent papers show that TCCC recommendations are being used by the United Kingdom, French, Israeli, Spanish, Belgian, Dutch, and Chinese militaries.

Thanks in large part to allied partner nations’ participation in the TCCC Working Group and to NAEMT’s worldwide educational infrastructure and its aggressive leadership in offering TCCC training internationally, TCCC has indeed “spread all around the globe.

References

Aldington D, Jagdish S: The fentanyl ‘lozenge’ story: from books to battlefield. J R Army Med Corps; 2014 Vol 160:102-104

Amor SP. ABCA Armies’ Program Chief of Staff letter. February 22, 2011.

Borgers F, Van Boxstael S, Sabbe M: Is tactical combat casualty care in terrorist attacks suitable for civilian first responders? J Trauma Acute Care Surg 2021 Oct 1;91(4):e86-e92.

Butler FK. Leadership Lessons Learned in Tactical Combat Casualty Care. J Trauma Acute Care Surg. 2017 Jun;82(6S suppl 1):S16-S25.

Butler FK. Two decades of saving lives on the battlefield: Tactical Combat Casualty Care turns 20. Mil Med. 2017;182(3):e1563-e1568.

Butler FK, Blackbourne LH. Battlefield Trauma Care Then and Now: A Decade of Tactical Combat Casualty Care. J Trauma Acute Care Surg. 2012;73(6)( Suppl 5):S395-402. doi: 10.1097/TA.0b013e3182754850.

Chen S, Yang J, Zhang L, Yang L, Qin H, et al: Progress on combat damage control resuscitation/surgery and its application in the Chinese People's Liberation Army. J Trauma Acute Care Surg 2019;87:954-960.

Cordier PY, Benoit C, Belot-De-Saint Leger F, Pauleau G, Goudard Y: Lessons Learned on the Battlefield Applied in a Civilian Setting. J Spec Oper Med 2021;21:102-105

de Rocquigny G, Dubecq C, Martinez T, Peffer J, Cauet A, Travers S, Pasquier P: Use of ketamine for prehospital pain control on the battlefield: A systematic review. J Trauma Acute Care Surg 2019; 2020;88: 180–185.

Goforth C, Antico D: TCCC Standardization the time is now. J Spec Oper Med. 2016;16:53-56.

Heldenberg E, Aharony S, Wolf T, Vishne T: Evaluating new types of tourniquets by the Israeli Naval special warfare unit. Disaster Mil Med 2015;1:1-7

Hooper TJ, Nadler R, Badloe J, Butler FK, Glassberg E. Implementation and execution of military forward resuscitation programs. Shock 2014:41 Supplement 1:90-97

Holcomb J: Major scientific lessons learned in the trauma field over the last two decades. PLoS Med 2017;14:e1002339.

Irizzary D. Training NATO Special Forces Medical Personnel: Opportunities in Technology-Enabled Training Systems for Skill Acquisition and Maintenance. J Special Ops Med Supplement, November 2013.

Johnston AM, Alderman JE: Thoracic Injury in Patients Injured by Explosions on the Battlefield and in Terrorist Incidents. Chest 2020; 157(4):888-897

Leeflang M, Woets R: How Tactical Combat Casualty Care (TCCC) Has Influenced Has Influenced Battlefield Trauma Care Worldwide. Oorspronkelijk (Ntherlands) article 2021;141-147.

Meusnier JG, Dewar C, Mavrovi E, Caremil F, Wey PF, Martinez JY: Evaluation of Two Junctional Tourniquets Used on the Battlefield: Combat Ready Clamp® versus SAM® Junctional Tourniquet. J Spec Op Med 2016; 16:41-46

Pannell D, Brisebois R, Talbot M, Trottier V, Clement J: Causes of death in Canadian forces members deployed to Afghanistan and implications on tactical combat casualty care provision. J Trauma. 2011;71: S401–S407

Planchon J, Vacher A, Comblet J, 3, Rabatel E, Mignon A, Pasquier P: Serious game training improves performance in combat life-saving interventions. Injury 2018;49:86-92.

Rogers E, Wright C, King P:Fentanyl lozenge story part 2: from military procurement to package. J R Army Med Corps 2018;164:458–462

Savage E, Forestier C, Withers N, Tien H, Pannel D. Tactical Combat Casualty Care in the Canadian Forces: lessons learned from the Afghan War. Can J Surg. 2011;59:S118-S123.

Sabate-Ferris A, Pfister G, Boddaert G, Daban JL, de Rudnicki S, et al: Prolonged tactical tourniquet application for extremity combat injuries during war against terrorism in the Sahelian strip. Eur J Trauma Emerg Surg 2021;Nov 14

Tien HC, Jung V, Rizoli SB, Acharya SV, MacDonald JC. An evaluation of Tactical Combat Casualty Care interventions in a combat environment. J Am Coll Surg. 2008;207:174-178.

Usero-Perez C, Alonso V, Peiro LO, Crespo JM, Lopez SH: Implementation of the Hartford Consensus and Tactical Combat Casualty Care recommendations in emergency services: a review of the literature. Emergencias 2017;29:416-421

Vysokovsky M, Avital G, Mahalo Y, Gelikas S, Fridrich L, et al: Trends in pre-hospital pain management following the introduction of new clinical practice guidelines. J Trauma Acute Care Surgery 2021;91: Supplement 2:206-212

Wang X, Xia D, Zhou P, Gui L, Wang Y: Comparing the performance of tourniquet application between self-aid and buddy-aid: in ordinary and simulated scenarios. AJTR 2021;13:6134-6141

Webster S, Barnard EBG, Smith JE, Marsden MER, Wright C: Killed in action (KIA): an analysis of military personnel who died of their injuries before reaching a definitive medical treatment facility in Afghanistan (2004–2014). BMJ Mil Health 2021;167:84–88.

#### Hartford Consensus and the ACS Stop the Bleed Program

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 can require tactics and training outside the parameters of many standard EMS protocols. The mass casualty incidents at Columbine High School, Virginia Tech, and Sandy Hook Elementary School 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.

The individual most responsible for helping to facilitate the translation of the military success with tourniquets and hemostatic dressings to the civilian sector is Hartford, Connecticut, trauma surgeon Lenworth Jacobs. In 2013, Dr. Jacobs convened the Hartford Consensus working group (the formal name of the group was the “Joint Committee to Create a National Policy to Enhance Survivability from Active Shooter and Intentional Mass Casualty Events.”) With Dr. Jacob’s advocacy, the Hartford Consensus was chartered by the American College of Surgeons (ACS) to identify measures that would help to improve survival for the victims of mass casualty incidents. He undertook this effort after the governor of Connecticut asked for his assistance in reviewing the tragic deaths in the Sandy Hook shootings and making recommendations about what measures might be undertaken to improve survival in future mass shooting incidents. Dr. Jacobs convinced the leadership of the ACS that the College should strongly advocate for improving the prehospital care for the victims of these incidents, primarily through the first responder use of tourniquets and hemostatic dressings to control external hemorrhage.

The Hartford Consensus Group included representatives from the White House, the Department of Defense, the Department of Homeland Security, and the ACS. The participants included national leaders in trauma surgery, Dr. Jacobs, the late Dr Norman McSwain (trauma director at the Spirit of Charity Hospital in New Orleans), Dr. Richard Carmona (former Surgeon General of the United States), Dr John Holcomb (the driving force behind many of the Department of Defense’s advances in trauma care during the recent conflicts), Dr. Frank Butler (Chair of the DoD’s Committee on TCCC), and Dr Ronnie Stewart (Chair of the ACS Committee on Trauma). Also included were leaders from law enforcement agencies (Drs. Dave Wade and Bill Fabbri from the FBI and Dr. Alex Eastman, from Dallas SWAT) as well as fire service agencies. The Hartford Consensus Group held a series of three meetings in 2013–2015 and published three advisory statements, which were compliled into the Hartford Consensus Compendium. This compendium has now been released as a Special Communication from the ACS.

In the first of the Hartford Consensus publications, Dr. Jacobs and the author group noted:

“One example of the lifesaving potential of TCCC guidelines is the renewed focus on prehospital tourniquet use. Before TCCC concepts were introduced, military medics were taught that a tourniquet should be used only as a last resort to control extremity hemorrhage. It is not surprising to note that a study of 2,600 combat fatalities from the Vietnam conflict and a second study of 982 fatalities from the early years of conflicts in Afghanistan and Iraq found that the incidences of death from extremity hemorrhage were essentially unchanged, at 7.4% and 7.8%, respectively…..However, after widespread implementation of the tourniquet recommendations from the TCCC guidelines, deaths from extremity hemorrhage became uncommon. A recent comprehensive study of 4,596 US combat fatalities from 2001 to 2011 noted that the incidence of preventable deaths from extremity hemorrhage had decreased remarkably to 2.6%.....The number of US lives saved from this single intervention has been estimated to be between 1,000 and 2,000."

The Hartford Consensus recommended that all professional first responders, to include EMS systems, law enforcement officers, and firefighters, should carry tourniquets and hemostatic dressings while carrying out their professional duties

This was a remarkable rethinking of the long-held position that tourniquet use in the prehospital phase of care for trauma victims should be avoided because it would result in an unacceptable incidence of limb loss due to tourniquet ischemia. The work done by COL John Kragh had clearly proven that this perception was false and that prehospital tourniquets were safe, effective, and lifesaving should the casualty actually have a major vascular injury. The recommendations of the Hartford Consensus were reinforced by the findings of the Prehospital Subcommittee of the American College of Surgeons in 2014. That group, led by Dr. Eileen Bulger, also agreed that the military experience with TCCC in Iraq and Afghanistan had proven tourniquets and hemostatic dressings had been effective in saving limbs and had caused only minimal morbidity when used for short periods of time. The Hartford Consensus was the springboard for the Stop the Bleed program, which was implemented by the ACS with the active support and endorsement of the White House.

Both the everyday trauma that occurs in the U.S. as well as the dramatic increase in terrorist attacks and so-called “active-shooter” incidents create the potential for a great many additional lives to be saved by using TCCC and Stop the Bleed concepts. Public awareness of such events and the ACS and White House advocacy for the Stop the Bleed program is already paying significant dividends in lives saved and has caused an acceleration of the translation of these two lifesaving interventions from the military to the civilian sector.

Two other factors that have also been important in accelerating this translation are the development of the civilian Tactical Emergency Casualty Care (TECC) program, which takes TCCC concepts and tailors them to better meet the tactical considerations that are encountered by law enforcement and firefighters in civilian high threat scenarios. In addition, the educational leadership displayed by The National Association of Emergency Medical Technicians (NAEMT) in offering courses in Prehospital Trauma Life Support, TCCC, and TECC around the world have made tactical medicine training widely available for organization that seek it. These initiatives and many other local, state, and regional efforts have ensured that the advances in prehospital trauma care pioneered by TCCC, the Joint Trauma System, and military medicine are being used to save lives in civilian trauma care practice with increasing frequency, notably by the law enforcement officers and firefighters that the Hartford Consensus Group identified as a previously underutilized source of lifesaving first responder care for trauma victims.

The impact of TCCC on civilian first responder trauma care and its subsequent incorporation into the Hartford Consensus and the White House/ACS Stop the Bleed program was summed up by Hawk:

“Tactical Combat Casualty Care has revolutionized prehospital care, dramatically reduced the incidence of preventable battlefield death, and spurred development of novel devices to arrest hemorrhage, such as junctional tourniquets and the X-Stat hemostatic device. The application of the lessons learned has transitioned to civilian practice. The American College of Surgeons convened senior leaders from the military medical, law enforcement, and emergency medical services communities to explore the civilian application of Tactical Combat Casualty Care in response to active-shooter mass casualty incidents. Those leaders generated the Hartford Consensus, which described a series of critical actions with the acronym THREAT. The second action was hemorrhage control. Launched in October 2015 by the White House, “Stop the Bleed” is a national awareness campaign managed through the Department of Homeland Security.”

References

Bulger EM, Snyder D, Schoelles K, Gotschall C, Dawson D, Lang E, Sanddal ND, Butler FK, Fallat M, Taillac P, et al. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014;18(2):163–73.

Butler FK: The Hartford Consensus: A Major Step Forward in Translating Battlefield Trauma Care Advances to the Civilian Sector; J Spec Op Med 2015;15:133-135

Butler FK, Carmona R: Tactical Combat Casualty Care: From the Battlefields of Afghanistan and Iraq to the Streets of America. The Tactical Edge. Winter 2012

Callaway DW. Translating Tactical Combat Casualty Care Lessons Learned to the High-Threat Civilian Setting: Tactical Emergency Casualty Care and the Hartford Consensus. Wilderness Environ Med. 2017 Jun;28(2S):S140-S145.

Callaway D, Robertson J, Sztajnkrycer M. Law enforcement-applied tourniquets: a case series of life-saving interventions. Prehosp Emerg Care. 2015;19:320-327.

Callaway DW, Smith ER, Cain J, Shapiro G, Burnett WT, McKay SD, Mabry R. Tactical emergency casualty care (TECC): guidelines for the provision of prehospital trauma care in high threat environments. J Spec Oper Med. 2011;11(3):104–122

Jacobs LM and the Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Shooting Events. The Hartford Consensus IV: A call for increased national resilience. Conn Med J. 2016;80:239-244.

Jacobs LM, Wade DS, McSwain NE, et al. The Hartford Consensus: THREAT, A Medical Disaster Preparedness Concept. J Am Coll Surg. 2013;217:947-953.

Jacobs LM, McSwain NE Jr, Rotondo MF, et al. Improving survival from active shooter events: The Hartford Consensus. J Trauma Acute Care Surg. 2013 Jun;74:1399-1400.

Jerome J, Pons PT, Haukoos JS, Manson J, Gravitz S: Tourniquet Application by Urban Police Officers The Aurora, Colorado Experience. JSOM 2021;21:71-76

Kragh J, Walters T, Westmoreland T, Miller R, Mabry RL, et al: Tragedy into drama: an American history of tourniquet use in the current war. J Spec Oper Med. 2013;13:5-25.

Kragh JF, Walters TJ, Baer, DJ, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009;249(1):1–7.

Kragh JF, Walters TJ, Baer DG, et al. Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma. 2008; 64(2)(suppl):S38–S49.

Levy M, Jacobs L. A call to action to develop programs for bystanders to control severe bleeding. JAMA Surg. 2016;151(12):1103-1104.

Pons P, Jerome J, McMullen J, et al. The Hartford Consensus on active shooters: implementing the continuum of prehospital trauma response. J Emerg Med. 2015;49:878–885.

Reed JR, Carman MJ, Titch FJ, Kotwal RS. Implementation and evaluation of a first-responder bleeding-control training program in a rural police department. J Spec Oper Med. 2018;18(3):57–61.

#### TCCC Transition to Civilian Health Care

#### TCCC in Civilian Trauma Systems

There is a common perception that military forces make significant advances in trauma care during times of war and that these advances will be translated as a matter of course to the civilian sector. While this may in general be a true statement, that process may be a prolonged one. TCCC has acknowledged from its beginning that decisions about battlefield trauma care would usually need to be made on the basis of imperfect evidence. Few decisions in combat are based on information that approaches the level of a randomized controlled trial and medical decisions are no exception. In approaching a clinical decision, the Committee on TCCC generally responds to new information by determining a specific question that needs to be answered, weighing the best evidence available when a decision is called for, making the requisite decision, and then revisiting that decision whenever important new evidence comes to light. Importantly, existing recommendations are subjected to the same best-evidence scrutiny that proposed new ones receive.

#### Civilian Medical Organizations and TCCC

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 Prehospital Trauma Life Support (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 and have been in every subsequent edition. This has been exceptionally helpful in translating TCCC concepts into use in the civilian sector in that the PHTLS textbook carries the endorsement of the American College of Surgeons and the NAEMT; this was the first step toward the mainstreaming of TCCC. Beginning with this initial interaction, a robust and ongoing dialogue developed between TCCC, PHTLS, and NAEMT. The strong partnership between NAEMT, PHTLS, the American College of Surgeons Committee on Trauma, and TCCC has endured and these groups have adopted a number of the recommendations made by the CoTCCC regarding prehospital trauma care. TCCC, in turn, has benefitted greatly from a robust dialogue with civilian trauma care experts and from the NAEMT educational infrastructure.

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. 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. 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. The TCCC and the WMS conducted a workshop in which they developed guidelines for combat casualty care in wilderness settings Fentanyl lozenges recommended for analgesia in TCCC were previously recommended for use in wilderness trauma care in 1999. Hemostatic dressings and tourniquets used in TCCC are the mainstays for controlling life-threatening external hemorrhage in the wilderness. TCCC-based techniques are now used to train medical personnel who provide care to trauma victims in our country’s national parks. 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.

Yet another group that has been a valuable partner with the CoTCCC in cross walking military innovations in trauma care to the civilian sector has been the American College of Emergency Physicians (ACEP). The endorsement of the American College of Surgeons and the College’s Committee on Trauma of the TCCC-led use of prehospital tourniquets and hemostatic dressings has been discussed previously. The ACEP likewise endorsed tourniquets and hemostatic dressings for the control of life-threatening external hemorrhage in the prehospital setting. Additionally, the ACEP has endorsed some of the TCCC-led advances in prehospital analgesia. The survey of prehospital trauma care in Afghanistan in November of 2012 led by Colonel (retired) Russ Kotwal, Colonel Stacy Shackelford, and Colonel Erin Edgar, produced very valuable feedback from combat medical providers about the state of battlefield analgesia in US forces. 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 COTCCC subsequently developed the "Triple Option Analgesia” concept. This plan for battlefield analgesia provides faster, safer, and more effective relief of pain from combat injuries than the intramuscular morphine that has been used by the US Military since the Civil War. 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 UK and the US Air Force PJ community. This plan that 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 sedation 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.

#### Specific TCCC Interventions in Civilian Pre-Hospital Trauma Care

As of 2021, many of the above TCCC recommendations are in various stages of transition to the civilian sector. Tourniquets have probably been the best example of a successful translation, largely because of the ease with which external hemorrhage can be identified as well as the ease with which tourniquets can be applied when needed, but also because of the pioneering efforts of Dr. Jacobs, the Hartford Consensus Group, and the American College of Surgeons discussed previously.

Prior to the onset of hostilities in Afghanistan in 2001, because of the widespread and erroneous belief that the risks of tourniquet use outweighed the benefits, civilian tourniquet use was almost non-existent. TCCC was virtually the only entity advocating for their prehospital use in trauma patients. By 2008, tourniquet use was ubiquitous in the U.S. military, but not in the civilian sector. In their 2019 paper, Goodwin and her co-authors examined the National Emergency Medical Services (NEMSIS) database from 2008 to 2016. The authors noted that in the years 2008 and 2009, in 8,940,451 EMS activations in the civilian sector, there were exactly 0 instances of tourniquet use. By 2016, there were 3995 instances of tourniquet use in 29,919,652 EMS activations. The authors attribute this dramatic change directly to the TCCC initiative, noting that:

“Over the past two decades, the early and judicious use of tourniquets for prompt control of life-threatening extremity hemorrhage has become the cornerstone of the US military's Tactical Combat Casualty Care (TCCC) program. It has substantially improved survival, particularly from compressible sites of hemorrhage and what were deemed “preventable deaths.”

It is not known how many potentially preventable deaths have occurred because of the lack of prehospital tourniquet use over the years, but there have been numerous papers that clearly document the lifesaving benefits of civilian tourniquet use in the recent past. Despite the well-documented success of tourniquets at saving lives in the civilian sector at this point in time, a December 2021 paper by Bulger noted that in the area surveyed in her study, “Although they observed an increase in the use of tourniquets over time, it is concerning that overall, only 10% of the cohort received a tourniquet, and in the last year of the study, 2019, only 18% received a tourniquet."

Another TCCC intervention that has translated well into the civilian EMS setting is hemostatic dressings. After having been a research priority for the U.S. military since the Battle of Mogadishu, hemostatic dressings were developed and tested at military medical research laboratories and widely used by combat troops after several year of conflict in Afghanistan and Iraq. Absent from civilian trauma systems prior to their being recommended by TCCC, hemostatic dressings are now widely reported to be used and of benefit in controlling external hemorrhage in the civilian sector.

Prehospital fluid resuscitation for trauma victims in hemorrhagic shock is a third example of military prehospital innovations translating well to the civilian sector. The prevailing wisdom regarding prehospital fluid resuscitation when the TCCC effort began in 1992 was the administration of large volumes of crystalloid (2 liters of normal saline or lactated Ringers.) The TCCC researchers found that this approach was not well-supported by the best evidence available at the time and recommended a different approach to prehospital fluid resuscitation, limiting the amount of crystalloid administered and using hetastarch solutions so that the fluid administered would remain intravascular for a much longer period of time than would be the case with crystalloid.

These initial recommendations continued to evolve throughout the course of the conflicts in Iraq and Afghanistan as evidence from those conflicts became available. The repositioning of the Committee on TCCC from the Defense Health Board to the Joint Trauma System in 2013 strengthened its tie with the military trauma surgery and critical care communities who were responsible for the in-hospital advances in trauma care, including a shift from predominantly red blood cell (RBC) resuscitation, to a balanced approach using a 1:1:1 volume ratio of plasma: RBCs:platelets and later to the preferential use of low-titer O whole blood (LTOWB.) The life-saving benefits of whole blood in the resuscitation of combat casualties in hemorrhagic shock has now been well-documented.

The recent conflicts have also provided evidence that whole blood and blood products improve survival when administered in the prehospital phase of care and should be administered as soon as possible when indicated. Shackelford et al reviewed the records of 502 casualties from Afghanistan and found that – quite literally – minutes matter. When casualties required a transfusion of either whole blood or blood components, the earlier they got them. the better their chances of surviving were, both at 24 hours and 30 days after wounding.

Later Gurney et al published several studies designed to determine the impact of fresh whole blood as compared to blood components in improving the survival of casualties who required transfusions. The researchers found that for severely injured casualties the risk of death was almost three times as great in those casualties who did not receive fresh whole blood.

The use of whole blood when feasible and RBCs or plasma when whole blood is not available may have a much larger impact on casualty survival in future conflicts that may see U.S. troops conducting combat operations in less mature theaters of conflict than Iraq and Afghanistan were in the later years of those wars. Military operations in the U.S. IndoPacific Command in particular may include shipboard casualties who may have prolonged evacuation times to a surgical capability.

On the civilian side, there is starting to be movement away from the old prehospital fluid resuscitation paradigm of large volume crystalloid. The recognition of LTOWB as a favorable option for the resuscitation by civilian organizations such as the American Association of Blood Banks has increased the visibility of this option in the civilian sector and a growing number of civilian EMS agencies have recognized that whole blood and other blood products offer a distinct survival benefit over large volume crystalloid solutions in the civilian sector.

In 2021, Guyette and colleagues conducted a comparison of resuscitation with electrolyte solution to resuscitation with blood products in severely injured patients who were transported by 27 helicopter emergency medical services, Prehospital administration of plasma and red blood cells was found to reduce mortality by 62% in comparison to electrolyte solutions. Hashmi et al reported that the proportion of American College of Surgeons-verified trauma centers transfusing whole blood for trauma patients was 16.7% (45/269) in 2015; that percentage had increased to 24.5% (123/502) by the first quarter of of 2020.

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