Several events that occurred prior to the onset of hostilities in Afghanistan were central to this transformation of battlefield trauma care. The Navy SEAL teams and the 75th Ranger Regiment began training all combatants in TCCC prior to the start of the current conflicts. The Army Special Missions Unit and the Air Force pararescue community also implemented TCCC from 1997 to 1998 and quickly adopted the practice of teaching TCCC to every combatant so that the most critical lifesaving interventions, like tourniquets, can be accomplished by every one of their unit members.9,50,51
After 10 years of intense combat operations in Iraq and Afghanistan by the Ranger Regiment, Kotwal and colleagues reported only one potentially preventable death among 32 combat fatalities (out of 419 casualties) sustained by the 75th Rangers,51 and the death that was deemed preventable occurred in the hospital, not the prehospital, setting. This finding stands in stark contrast to the 15% to 28% of preventable deaths reported in other studies among U.S. casualties in these conflicts.27,32,34Considering the prehospital phase only, potentially preventable deaths among fatalities in the 75th Rangers was zero as compared to 24% in the study by Eastridge et al.32 The remarkable disparity in potentially preventable deaths between early adopters of TCCC and the rest of the U.S. military was not widely known until the Kotwal study was published in 2011, followed by the Eastridge study in 2012. Observed differences in potentially preventable deaths may be due to differences in the methodology of determining which deaths are considered potentially preventable or differences between the casualty cohorts reported. Nevertheless, in 2017 little disagreement that the interventions pioneered by TCCC reduce preventable deaths during the phase of care when they are most likely to occur has been offered.
As noted earlier, the transition from previous prehospital trauma care regimens to TCCC was well under way in the U.S. military by 2011. This happened because of a very specific sequence of events that has been well documented but is not widely known. When U.S. forces invaded Afghanistan in 2001, there was no JTS in place and thus no mechanism for the systematic review of combat casualty care outcomes in the U.S. military to seek opportunities to improve care.52 Specifically, from 2001 to 2004, there was no DoD focus on the causes of preventable deaths among U.S. fatalities and how they could have been prevented, and TCCC was primarily used only by those units that had adopted these new concepts before 2001. Adoption of TCCC required a move away from long-standing and firmly entrenched approaches to battlefield trauma care. How did this widespread change of culture finally come about?
The first and most fundamental requirement for changing the culture in battlefield trauma care was to provide a much higher-quality set of recommendations. As recounted in recent publications,8,9,21 there were three aspects of the TCCC development process that enabled these improved recommendations. First, 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 care. Second, the actual conditions that combat medical personnel were likely to 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 incorporated throughout the TCCC development process.
The second step in changing the culture in battlefield trauma care, and the one that first led to the spread of TCCC beyond the few early adopters, was the first preventable death review of U.S. fatalities from Iraq and Afghanistan. In 2004, the USSOCOM had two critically important questions that needed to be answered: (1) what specifically were our Special Operations combat casualties dying from, and (2) what, if anything, could have been done to prevent those deaths? One might reasonably assume that the DoD had always performed preventable death reviews on its combat fatalities, but, as of 2004, there was no formal process to review combat deaths and to use that information to save the lives of future casualties. USSOCOM called upon Col. John Holcomb, who was then the Commander of the USAISR, 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 like a tourniquet.27 This study sent a clear signal that TCCC training and equipment were 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 step in changing the culture also resulted from a collaboration between USSOCOM and USAISR. After the documentation of preventable deaths in the Holcomb study, the leadership of USSOCOM supported 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 trainingand equipment to deploying Special Operations units, but also collected feedback from medics, corpsmen, and PJs when these units returned from combat operations. It also provided early documentation of the success of TCCC interventions.8,21,37
The fourth event that led to the widespread adoption of TCCC concepts was a U.S. Central Command (CENTCOM) 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, Lt. Gen. Doug Robb. Although the services have the primary responsibility for training and equipping combatants, this mandate from CENTCOM forced supervising medical officers throughout the services to rethink their many years of medical training that had consistently taught them that the use of extremity tourniquets was a very bad idea.
The fifth key element that helped to change the culture of battlefield trauma care in the military was the excellent documentation of the impact of tourniquet use. It is often difficult to identify with precision which elements of TCCC are responsible for saved lives, but tourniquets are an exception to this rule. The work of Col. John Kragh, an orthopedic surgeon working at the Ibn Sina Hospital in Baghdad, reported that 31 lives were saved with tourniquets at his facility in one 6-month period.8,28-30 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 possibly been saved with tourniquets in those conflicts. Again, these successes with tourniquet use were obtained without loss of limbs to tourniquet ischemia. Col. Kragh’s work irrefutably confirmed the lifesaving benefits of what was perhaps the single most controversial aspect of TCCC.8
The sixth essential step in changing the culture of the U.S. military to accept TCCC was effective strategic messaging. The success of the TCCC Transition Initiative, Col. Kragh’s work, and the decreased incidence of preventable deaths in units that were early TCCC adopters were presented frequently at military medical conferences and in the published medical literature.29,30,33,36,37,42,44,45,47 The dramatically lower proportion of preventable deaths in the 75th Ranger Regiment compared to that in the broader U.S. military in which TCCC was adopted later was widely acclaimed in the medical literature. This acclamation increased awareness among combat medical personnel and their physician and physician assistant supervisors of the success of TCCC in reducing preventable deaths. These reports also provided TCCC innovators with published evidence that they could present to their unit commanders.32,51
Finally, evidence alone is often not effective in driving advances in trauma care,21 and this and other difficulties inherent in making changes in battlefield trauma care have been identified.52,53 Divided lines of authority and distributed responsibilities in the military structure make it exceedingly difficult to optimize battlefield trauma care throughout the DoD. Butler, Smith, and Carmona described the problem this way:52
“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 U.S. Military has four armed services, six Geographic Combatant Commands, the U.S. Special Operations Command and the U.S. 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 Chiefs of Staff, and Service leadership levels, the span of responsibilities is immense. The ability of leaders at this level to focus on and mandate aspects of trauma care that are vigorously debated even among trauma subject matter experts is very limited. Therefore, when change is effected in battlefield trauma care, it typically occurs at a significantly lower level in the military chain of command and benefits only those individuals in that part of the organization.
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 was not a doctor, but his decision paved the way for saving hundreds of lives among U.S. combat casualties.8,9,21
A similar occurrence took place in the 75th Ranger Regiment. In 1997, the regiment’s commander, 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.51 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, and so every Ranger received training in TCCC.21,54
Likewise, Gen. Doug Brown and VADM Eric Olson at the U.S. Special Operations Command mandated TCCC at a time when it was not the standard of care for prehospital trauma care, either in the U.S. military or in the civilian sector. General John Abizaid at the CENTCOM did much the same thing in requiring the use of tourniquets in Iraq and Afghanistan at a time when conventional wisdom dictated otherwise.
The first takeaway from this discussion of the importance of leadership in advancing battlefield trauma care is that new evidence alone does not drive advances in trauma care—in either the civilian sector or the military—people do that.
The second takeaway is that it is often not trauma subject matter experts who are the final decision makers in introducing new standards of trauma care. Both in the military and in the civilian sector, decision makers at senior levels are often not the subject matter experts. As former U.S. Surgeon General Rich Carmona pointed out during the Hartford Consensus IV meeting,55 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 here—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 both their professional reputations and resources to do so.21,54