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.

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