• Category TECC/TCCC/Active Shooter
• Views 39,774

Once again… TCCC is revolutionary, when applied in the environment for which it was designed....

Previous to TCCC, combat trauma training for the special forces medic was based on the principles and treatment modalities of Advanced Trauma Life Support (ATLS).   “The ATLS guidelines provide a standardized, systematic approach to the management of trauma patients that has proven very successful when used in the setting of civilian hospital emergency departments”,^1,2 but the efficacy of at least some of these measures in the prehospital setting had been questioned.^1,2,  Also critical to note, the ATLS guidelines were never critically evaluated for efficacy or application for battlefield integration, many military medical authors published some of the shortcomings of ATLS specific to battlefield implementation.^{1-30,33-39,42,43}

“The 18 Delta course structures its trauma care around the principles taught in ATLS. These principles are supplemented by trauma care training in a field environment, but the departures from ATLS appropriate for the battlefield have not been systematically reviewed and presented in the literature. In addition, many of the unique operating environments and missions encountered in Special Operations are not addressed. “- Tactical Combat Casualty Care in Special Operations²

Some of the “unique environments” or environmental pathology present in tactical operations which are not accounted for in civilian trauma guidelines includes, but not limited to; Hostile fire, darkness, environmental extremes, different wounding epidemiology, limited equipment and resources, need for tactical maneuver, long delays to hospital care, and different medic training and expertise.

These battlefield specific environmental factors combined with COL Ron Bellamy’s article, How People Die in Ground Combat (1984) and injury data extrapolation from the Vietnam era WDMET study³⁹, provided the foundation in which to alter military prehospital trauma care forever.  The new methodology published in 1996 emphasized 3 overarching objectives: (1) treat the patient, (2) prevent additional casualties, and (3) complete the mission. It also presented 3 phases of care: (1) care under fire, (2) tactical field care, and (3) casualty evacuation care. These centered on preventing the 3 major, potentially survivable causes of death: (1) extremity hemorrhage exsanguination, (2) tension pneumothorax, and (3) airway obstruction.^1,2,40-43 Included with these new guidelines were a complete overhaul of treatment modalities and priorities which stood in direct contrast to what was previously considered the standard.  

Because TCCC guidelines diverged from accepted mainstream civilian standards for Advanced Trauma Life Support–based prehospital care, initial acceptance in the US military was slow and met with significant opposition.^1,41,43  In contrast, Army Rangers and Navy SEALs (Sea, Air, and Land Teams) extensively implemented TCCC on its inception.⁴¹ The evidence-based TCCC guidelines have continued to evolve into a formal Committee on TCCC, founded in 2001 and currently reporting through the Defense Health Board to the Assistant Secretary of Defense for Health Affairs.⁴⁵ 

Although TCCC would start off in Special Operations, it has permeated into all branches of the military, and in most branches, at entry non-medic levels.  It has effectively pushed out critical basic lifesaving interventions to the non-medic operator level.  Due to this permeation to conventional units, TCCC has lost relevance to special operations except for verbiage, but has reached an exponential number of consumers.  As a result of the proliferation of TCCC, casualty data from Operation Enduring Freedom (OEF) & Operation Iraqi Freedom (OIF) shows that TCCC training, along with improved personal protective equipment, faster evacuation times, and better trained medics have produced the best casualty survival rate in U.S. history.⁴⁵ 

TCCC turned out to be not just innovative but revolutionary to military prehospital trauma care.  It also spread out medical capabilities across the battlefield by empowering the non-medic combatant.  TCCC identified the three most potentially preventable causes of death on the battlefield, allowing every soldier, sailor, and airman to be trained and equipped to manage these injuries on themselves or their buddy.  The days of the medic running from casualty to casualty across the battlefield, with no prior medical treatments administered were quickly becoming a thing of the past.  This highlighted the infamous quote of Dr. Nicholas Senn in 1897, “The fate of the wounded rests with the one who applies the first dressing”. 

Historically, approximately 90% of combat-related deaths occur prehospital, prior to the casualty reaching a medical treatment facility.  Reviewing U.S. military fatality data prior to full TCCC integration, reports potentially preventable deaths to range from 15% to 28%.⁴⁵ In 2011 Dr. Kotwal (et al) published a 0.0% fatality rate of potentially preventable prehospital deaths within the 75th Ranger Regiment between October 1, 2001 through March 31, 2010, after initiating a comprehensive command-directed casualty response system that trains all personnel in TCCC.⁵³ TCCC unquestionably, forced civilian medicine to re-examine its position and priority on tourniquet utilization, hemostatics, fluid resuscitation, pain control, and cervical-spine immobilization.

The Need, The Void…” The Easy” Button

As TCCC gained popularity, published articles and research pertaining to these new guidelines caught the attention of the civilian market.  Federal and municipal law enforcement SWAT members saw the relevance and TCCC began to permeate into the lexicon of civilian tactical EMS.^47,48,51 There was push back, specifically from medical directors and EMS supervisors, but gradually TCCC found its way into civilian special operations training and “best practices”.^47,48 When evaluating the relevance of utilizing military trauma guidelines within civilian tactical operations, on the surface, it seemed reasonable.  Of course there were differences, from body armor specifications and ratings (many civilian tactical teams still use vests rated at Level IIIA), individual health requirements for entry into military and law enforcement differ, and injury correlation to weapon systems utilized (GSW vs. Explosive) between the two realms are skewed.^48,49,51  But, at the time (late 1990’s - early 2000’s) there were no other relevant trauma care guidelines focused on penetrating injuries, and TCCC seemed to be the “easy button”.

TCCC is an evidence-based guideline set forth by the Committee on Tactical Combat Casualty Care (CoTCCC) and reviewed by the Defense Health Board.   It is critical that the end-user understands what evidence-based medicine is and how this systematic approach could affect its integration and application into real-world environmental pathology.  This blog will not go into all the specifics, but we do go into it on our HRO PodCast Series.  The civilian community must realize that the TCCC guidelines contain a few innate assumptions that exist in military operations and with its’ personnel (in which TCCC is written) that are not present in the civilian law enforcement counterpart.  A partial list includes;

• Data and research heavily based off of healthy 18-30-year-old population (primarily male)

• Data and treatment modalities heavily influenced by disproportionate ground level explosive devices (Holcomb)

• Combatants wearing issued Level IV Body Armor (many with groin and bicep protection), Kevlar helmets, and ballistic eye protection

• Tactical maneuvers and rules of engagement (ROE)

We cannot underestimate or dismiss injury patterns and personal protective equipment (PPE).    Recall improved PPE was listed as a major contributing factor of decreasing mortality in combat to the lowest levels ever in U.S. history.⁴⁵ Even within civilian special operations there are many teams wearing Level IIIA, not Level IV body armor, which will alter injury distribution significantly, let alone the prevalence of ground level improvised explosive devices.  When looking at law enforcement as a whole, the body armor level can go down to level II and IIA for non-tactical personnel.  To further complicate the issue, civilian law enforcement does not have an equivalent to the military’s Joint Theater Trauma System or Joint Theater Trauma Registry (JTTR), this means there is not an official database to reference law enforcement injury patterns, PPE, and prehospital treatments during violent encounters.  

Within the military, especially when discussing conventional units, there is consistency not accounted for in the civilian sector.  Soldiers, sailors, and airmen are issued PPE, medical gear, and work within prescribed rules and regulations, which are routinely inspected for consistency.  This is not true in the civilian sector.  There is no national standard in PPE, medical gear, protocols, or response capabilities which all first responders must adhere.  Upon examination, civilian law enforcement may have been trying to integrate TCCC into their specific environment in a similar manner that the military was utilizing ATLS.

There were two main precipitating factors that brought this “one-size fits all” solution of TCCC in civilian application to the attention of many, 1) equipment failures and its relation to evidence-based medicine, and 2) the Hartford Consensus and its TCCC-based recommendations for civilian first responders and bystanders.

Shortly after the formation of the CoTCCC and the inclusion of recommended equipment into their guidelines, disconcerting reports of recommended operational equipment failures would come to light.  A sample of these failures include, tourniquet windlasses (constructed of composite material) breaking, antibiotics not constituting in the heat of deployed regions, junctional devices that consistently fail during movement / rescue situations, and the realization that the fluid resuscitation recommendations were based on years of compromised research. 

How could these and other operational equipment failures occur within an Evidence-Based Guideline…?  Well that was covered in Part 1 of this series.  But it has to do with “what is evidence-based medicine?”  It is a bell curve, done in a sterile lab, with limited variables…specifically THE ENVIRONMENT.  Also remember outliers can be dismissed, but in reality, everything we do involves environmental pathology…and most of our responses are or at least contain outliers. 

The answer…Enter TECC.

References & Recommended Resources

1. Butler FK. Hagmann J, Richards DT: Tactical Management of Urban Warfare Casualties in Special Operations.  Military Medicine 2000: 165 (Suppl) : 2-48.
2. Butler FK. Hagmann J, Butler EG: Tactical combat casualty care in special operations. Military Med 1996: 161 (Suppl): 3-16.
3. Alexander RH. Proctor HJ: Advanced Trauma Life Support 1993 Student Manual. Chicago, American College of Surgeons, 1993.
4. Arishlta GI. Vayer JS, Bellamy RF: Cervical spine immobilization of penetrating neck wounds in a hostile environment. J Trauma 1989; 29: 332-7.
5. BickeII WI-i. WaU MJ. Pepe PE. et al: Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N EngI J Med 1994: 331: 1105-g.
6. Honlgman B. Rohwder K. Moore EE, et al: prehospital advanced trauma life support for penetrating cardiac wounds. Ann Emerg Med 1990: 19: 145-50.
7. Smith JP. Bodai BI: The urban paramedic’s scope of practice. JAMA 1985; 253: 544-8.
8. Smith JP, Bodai BI, HilI AS, et al: Prehospital stabilization of critically injured patients: a failed concept. J Trauma 1985: 25: 65-70.
9. Dronen SC, Stem S, BaIdursson J, et al: Improved outcome with early blood administration in a near-fatal model of porcine hemorrhagic shock. Am J Emerg Med 1992; 10: 533-7.
10. Stem SA. Dronen SC, Birrer P, et al: Effect of blood pressure on hemorrhage volume and survival In a near-fatal hemorrhage model incorporating a vascular injury. Ann Emerg Med 1993: 22: 155-63.
11. Chudnofsky CR, Dronen SC, Syverud SA, et al: Early versus late fluid resuscitation: lack of effect in porcine hemorrhagic shock. Ann Emerg Med 1989; 18: 122-6.
12. BickeIl WH: Are victims of injury sometimes victimized by attempts at fluid resuscitation (editorial)? Ann Emerg Med 1993: 22: 225-6.
13. Chudnofsky CR, Dronen SC, Syverud SA. et al: Intravenous fluid therapy in the prehospital management of hemorrhagic shock: improved outcome with hyper-tonic saline /6% d&ran 70 in a swine model. Am J Emerg Med 1989; 7: 357-63. 12. Martin RR, BickeII WH, Pepe PE, et aI: Prospective evaluation of preoperative fluid resuscitation in hypotensive patients with penetrating truncal injury: a preliminary report. J Trauma 1992; 33: 354-61.
14. Kaweski SM. Sise MJ, Virgilio RW: The effect of prehospital fluids on survival in trauma patients. J Trauma 1990; 30: 1215-8.
15. Gross D. Landau EH. Klin B, et al: Treatment of uncontrolled hemorrhagic shock with hypertonic saline solution. Surg Gynecol Obstet 1990; 170: 106-12.
16. Deakin CD, Hicks IR: AB or ABC: pre-hospital fluid management in major trauma. Journal of Accident and Emergency Medicine 1994; 11: 154-7.
17. BickeII WI-L BrutUg SP. Mtiamow GA, et al: Use of hypertonic saline/dextran versus lactated Ringer’s solution as a resuscitation fluid after uncontrolled aortic hemorrhage in anesthetized swine.  Ann Emerg Med 1992; 21: 1077-85.
18. Dontigny L: Small-volume resuscitation. Can J Surg 1992: 35: 313.
19. Krausz MM, Bar-Ziv M, Rabinovici R. et al: “Scoop and run” or stabilize hemorrhagic shock with normal saline or small-volume hypertonic saline? J Trauma 1992; 33: 6-10.
20. Gross D. Landau EH. Assalita A, et al: Is hypertonic saline resuscitation safe in uncontrolled hemorrhagic shock? J Trauma 1988; 28: 751-6.
21. KowaIenko J, Stem S, Dronen S. et al: Improved outcome with hypotensive resuscitation of uncontrolled hemorrhagic shock in a swine model. J Trauma 1992: 33: 349-53.
22. Za]tchuk R, Jenkins DP, Bellamy RF, et aI (eds): Combat Casualty Care Guidelines for Operation Desert Storm. Washington, DC, Offlce of the Army Surgeon General, February 1991.
23. Krausz MM, KIemm 0. AmsUslavsky T, et al: The effect of heat load and dehydration on hypertonic saline solution treatment on uncontrolled hemorrhagic shock. J Trauma 1995: 38: 74752.
24. Napohtano LM: Resuscitation following trauma and hemorrhagic shock: is hydroxyethyl starch safe? Crit Care Med 1995: 23: 795-6.
25. Krausz MM: Controversies in shock research: hypertonic resuscitation-pros and
25. cons. Shock 1995; 3: 69-72.
26. BickelI WH, Shaftan GW, Mattox KL: Intravenous fluid administration and uncontrolled hemorrhage (editorial). J Trauma 1989; 29: 409.
27. Craig RL, Poole GV: Resuscitation in uncontrolled hemorrhage. Am Surg 1994;  60: 59-62.
28. Owens TM, Watson WC, Prough DS, Uchida T. Kramer GC: Limiting initial resuscitation of uncontrolled hemorrhage reduces internal bleeding and subsequent volume requirements. J Trauma 1995; 39: 200-7.
29. Pons PT, Honigman B. Moore EE. et al: Prehospital Advanced Trauma Life Support for Critical Penetrating Wounds to the Thorax and Abdomen. J Trauma 1985: 25: 82832.
30. Trunkey DD: Is ALS necessary for pre-hospital trauma care (editorial)? J Trauma 1984; 24: 86-7.
31. Bellamy RF: How Shall We Train for Combat Casualty Care? Milit Med 1987; 152:617-22.
32. Baker MS: Advanced trauma Life Support: Is It Adequate Stand-Alone Training for Military Medicine? Milit Med 1994; 159: 587-90.
33. Wiedeman JE. Jennings SA: Applying ATLS to the GulfWar. MiIit Med 1993; 158: 121-6.
34. Wound Data and Munitions Effectiveness Team: The WDMET Study. Uniformed University of the Health Sciences: Bethesda, Md., 1970.
35. Heiskell LE. Carmona RI-I: Tactical emergency medical services: an emerging subspecialty of emergency medicine. Ann Emerg Med 1994; 23: 778-85.
36. Ekblad GS: Training medics for the combat environment of tomorrow. MiIit Med 1990; 155: 232-4.
37. Baker MS: The acutely injured patient. Milit Med 1990; 155: 215-7.
38. Oreck SL: Improving military trauma care (letter). Milit Med 1994; 159: A3.
39. Bellamy RF: The causes of death in conventional land warfare: implications for combat casualty care research. Milit Med 1984; 149: 55-62.
40. McKay S. Johnston J. Callaway D. Redefining Technical Rescue and Casualty Care for SOF: Part 1. Journal for Special Operations Medicine Winter 2012; 86 - 93
41. Kotwal RS, Montgomery HR, Kotwal BM, Champion HR, Butler FK, Mabry RL, Cain JS, Blackbourne LH,  Mechler KK, Holcomb JB. Eliminating Preventable Death on the Battlefield. Arch Surg. 2011;146(12):1350-1358.  doi:10.1001/archsurg.2011.213
42. Butler FK Jr. Tactical medicine training for SEAL mission commanders.  Mil Med. 2001;166(7):625-631
43. Butler FK Jr, Holcomb JB, Giebner SD, McSwain NE, Bagian J. Tactical combat casualty care 2007: evolving       concepts and battlefield experience.  Mil Med. 2007;172(11):(suppl)  1-19
44. National Association of Emergency Medical Technicians.  Prehospital Trauma Life Support. 7th military ed. St Louis, MO: Mosby; 2011
45. John B. Holcomb, MD, Lynn G. Stansbury, MD, Howard R. Champion, FRCS, Charles Wade, PhD, and Ronald F. Bellamy, MD.  Understanding Combat Casualty Care Statistics. J Trauma. 2006;60:397-401
46. Butler FK, Blackbourne LH.  Battlefield Trauma Care Then and Now: A decade of Tactical Combat Casualty Care. J Trauma. 2012;vol 73, number 6, suppl 5: 395-400
47. Gerold K, Gibbons M, McKay S. The Relevance of Tactical Combat Casualty Care (TCCC) guidelines to civilian law enforcement operations. Tactical Edge. Fall 2006;52-60
48. Callaway, DW; Smith, ER; Shapiro, G; Cain, JS; McKay, SD; Mabry, RL.  The Committee for Tactical Emergency Care (C-TECC): Evolution and Application of TCCC Guidelines to Civilian High Threat Medicine. JSOM. 2011; Vol. 11, Ed. 2: 94-99
49. Callaway DW; Smith ER; Cain J; Shapiro G; Burnett WT; McKay SD; and Mabry R. Tactical Emergency Casualty Care (TECC): Guidelines for the Provision of Prehospital Trauma Care in High Threat Environments. JSOM. 2011; Vol. 11, Ed. 3: 104-122
50. Fabbri WP. Improving Survival in Active Shooter Events: The FBI’s view two years after Sandy Hook. JEMS, Law Officer, Fire Rescue, and Fire Engineering. Editorial Supplement: When Time Matters Most: Care at the Active Shooter & High Threat Incidents. 2014; 4-9
51. Smith RE, Callaway DW.  Tactical Emergency Casualty Care: The need for & evolution of civilian high threat guidelines. JEMS, Law Officer, Fire Rescue, and Fire Engineering. Editorial Supplement: When Time Matters Most: Care at the Active Shooter & High Threat Incidents. 2014; 10-15
52. Taillac PP.  Stop the Bleeding: New external hemorrhage control evidence-based guideline.  JEMS, Law Officer, Fire Rescue, and Fire Engineering. Editorial Supplement: When Time Matters Most: Care at the Active Shooter & High Threat Incidents. 2014; 18-21
53. The Interagency Board - Health, Medical & Responder Safety Subgroup.  Law Enforcement Tactical Emergency Casualty Care (TECC) Training and Individual First Aid Kits (IFAK) White Paper.  June 2015
54. FEMA.  U.S. Fire Administration: Fire / EMS Department Operational Considerations and Guide for Active Shooter and Mass Casualty Incidents. September 2013.
55. Office of Health Affairs / Department of Homeland Security. First Responder Guide for Improving Survivability in Improvised Explosive Device and / or Active Shooter Incidents. June 2015
56. IAFF.  Position Statement: Rescue Task Force Training. services.prod.iaff.org/ContentFile/Get/17073