Training Supplement - United States Special Operations Command

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Documenting feedback from the battlefield First-responder feedback is critical to adjusting the TCCC guidelines based on current experiences. Although physicians and physician assistants have historically provided at least some formal feedback in the way of published case reports and case series, feedback from combat medical personnel has been limited and essentially absent from nonmedical first responders. The recently established Joint Theater Trauma System (Eastridge et al., 2006) has made major advances in trauma care in the CENTCOM theater of operations. The trauma registry established as part of this effort could potentially address this issue successfully, but other methods of obtaining accurate, timely, first-responder input on how new TCCC equipment and strategies are working on the battlefield must be pursued as well. The TCCC Transition Initiative had some success in this area, but the data collected from returning combat medical personnel was limited due to collection methodology, concerns for operational security, and medic availability. The first responder forums conducted by senior enlisted leaders in the combat medical community, such as those organized by SGM Harold Hill, MSG Ted Westmoreland, and MSG Harold Montgomery and presented at the last three Special Operations Medical Association conferences are excellent sources of input that should be encouraged and developed (Butler et al., 2006). CoTCCC resourcing Since 2001, the CoTCCC has been the body responsible for updating the TCCC guidelines. With the expanding use and documented success of these guidelines, the function of this committee becomes increasingly important, especially because accounts of battlefield experiences will be forthcoming from the present conflict for several years to come. This information needs to be assimilated and the guidelines adjusted as appropriate. This step will be an ongoing, all-service effort that should be funded at an appropriate level. The CoTCCC leadership is working to secure the resources necessary to meet the demands generated by the success of the TCCC guidelines to date. Optimal TCCC training strategies Presently, there are a number of military and civilian courses that teach TCCC. The relative strengths and weaknesses of each course have not been well defined. Sohn et al.’s report (2006) of the four-day program at Madigan noted that classroom scenarios, simulators, and live tissue were all part of the framing. The authors stressed the importance of the live tissue framing in overcoming the “frozen in place” reaction observed by the instructors in many of the course attendees when confronted for the first time with seemingly uncontrollable hemorrhage from a proximal femoral artery injury. The importance of live tissue training in preparing medics to care for combat casualties was also stressed by the presenters at a recent military lessons learned conference (Jarvis et al., 2007) and in first-responder forums (Butler et al., 2006). Carefully defining exactly what injuries to treat and what procedures to perform is an essential element of optimizing live tissue training. Establishing a surgical airway is probably the procedure for which live tissue training is most beneficial. Other procedures for which live tissue framing may be particularly helpful include applying tourniquets and hemostatic dressings, needle thoracostomy, chest tube insertion, and using direct pressure to stop severe bleeding (Brown, 2005a). TCCC courses currently in use range from 2 to 11 days. The best combination of training techniques and the most cost efficient methods of presenting TCCC concepts and skills remains to be determined, and TCCC courses may have to be customized for various units’ particular needs. Fall 2008 Supplement 27
Future Issues New techniques and technologies may offer great opportunities for improving combat trauma care in the future. The CoTCCC should monitor the success of all currently recommended management strategies as additional information becomes available and identify areas where modifications are needed or further research is necessary. Modified configurations of the currently used HemCon and QuikClot have recently become available (Chitoflex and the QuikClot Advanced Clotting Sponge.) In addition, a number of promising new hemostatic agents are available. The hemostatic agent options for first responders need to be reevaluated in a comparative trial using appropriate animal models. Recombinant factor VIIa has been a useful adjunct to stopping uncontrolled bleeding in animal models (Howes et al., 2007) and in medical treatment facilities (Martinowitz et al., 2004; Holcomb, 2005b). This agent may have a role in certain selected prehospital settings in military operations, especially those in areas such as Afghanistan, where evacuation times are often much longer than those in Iraq. The two most promising interventions for avoiding preventable deaths in the study by Holcomb et al. (2007a) besides proper performance of TCCC were faster CASEVAC and/or an IV hemostatic agent. The deployment strategy and the indications for the potential use of factor VIIa in the prehospital setting would both need to be carefully defined. Optimum prehospital resuscitation strategies may continue to evolve. Hemoglobin-based oxygen carrying resuscitation fluids may become available in the near term. If they are approved by the FDA, the relative merits of these agents as compared to the current Hextend resuscitation strategies should be evaluated. The aggressive administration of fresh frozen plasma in a 1:1 ratio with PRBCs has been shown to decrease mortality dramatically in a hospital setting (Holcomb et al., 2007b), and this modality may have a place in selected prehospital settings. Department of Defense researchers are pursuing a comprehensive approach to fluid resuscitation that will address the multiple factors that must be considered, including preventing or reversing coagulopathies, oxygen-carrying considerations, duration of effect, and preventing iatrogenically-induced rebleeding (Holcomb et al., 2007b). The principles and technologies that ensue from these investigations will apply mostly to care in medical treatment facilities but may be useful in some prehospital settings. A common problem on the battlefield is managing severe pain in a casualty who is in shock or in danger of going into shock. Morphine and fentanyl are effective analgesics but are also cardiorespiratory depressants. Intranasal or IV ketamine or other medications that provide analgesia without depressing respiration and circulation should be evaluated for use by combat medics. 28 Journal of Special Operations Medicine
Page 1 and 2: Tactics, Techniques, and Procedures
Page 4: Abstract When United States Army Sp
Page 7 and 8: Dental operatories 3 Ancillary Lab,
Page 10 and 11: Chapter 2 Joint Lessons Learned Inf
Page 12 and 13: Chapter 3 Tactical Combat Casualty
Page 14 and 15: guidelines published in 1996 are pr
Page 16 and 17: After the USAISR study, the CAT was
Page 18 and 19: tourniquet prematurely (Butler et a
Page 20 and 21: Another is a report of the intracra
Page 22 and 23: second intercostal space in the mid
Page 24 and 25: hypotensive resuscitation is more e
Page 26 and 27: initial dose of 800/ig of OTFC, wit
Page 28 and 29: among unit members may result if ca
Page 32 and 33: Tactical Combat Casualty Care Guide
Page 34 and 35: Fluid resuscitation: Assess for hem
Page 36 and 37: Communicate with the casualty if po
Page 38 and 39: If not in shock: If in shock: • N
Page 40 and 41: Acknowledgments Many individuals co
Page 42 and 43: F.K. Butler and J. Hagmarm, eds.,
Page 44 and 45: J.H. Holcomb, S.T. Kerr, J.M. Macai
Page 46 and 47: N.E. McSwain, S. Frame, and J.P. Sa
Page 48: D.D. Watts, A. Trask, and K. Soeken
Page 51 and 52: Following is a copy of the “Kanda
Page 54 and 55: Overview Chapter 4 The Role of Medi
Page 56 and 57: U.S. military forces are explicitly
Page 58 and 59: Army (ANA) and Afghan National Poli
Page 60 and 61: After a female Afghan National Army
Page 62 and 63: priorities. This assessment process
Page 64: consideration of alternatives to po
Page 67 and 68: medic classes per year and five par
Page 69 and 70: Section II: Unconventional Warfare
Page 71 and 72: Learn to get along with others; som
Page 73 and 74: • Save coalition lives. • Kill
Page 75 and 76: schedules, abdominal pain, dengue f
Page 77 and 78: and allows for medical operations i
Page 79 and 80: Equipment THF increases the require
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Section VI: Critical Care Medical E
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º Unsecured airway: LMA, Combitub
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º Phenylephrine: 1 vial in 250ml
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Doctrinal Changes from the AMEDD Ro
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Role 4 Role 4 medical care is found
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Section VIII: MEDCAPS and COWCRAP C
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Background Section IX: 75th Ranger
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Medical assets include company seni
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y hoist/stokes litter. Performed ta
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References 1. G.E. Peoples, T. Gerl
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Talk to the local government, publi
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Special cases normally include roug
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• Establish medical clinics at ea
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Medics must understand the medical
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• Failure to focus combat forces
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Chapter 6 Female Treatment Team Aft
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º TB:15,000 deaths/year (12,000-13
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º Cerumen impaction º RAD º Flat
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The number of providers varied for
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MEDCAP: Common complaints from the
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Communication Firebase clinic: It w
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MEDCAP: The air transportation to t
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Providers Firebase clinic: Two 18Ds
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Cortisporin Otic drops Cepacol thro
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Topic: Predeployment medical readin
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stations. Many online medical sites
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medical treatment facilities (MTFs)
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Member perspectives on this observa
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tied to this number via a battalion
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Chapter 8 Guidelines for the Preven
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Current Situation The management of
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ecommendations are not applicable t
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Staphylococcus, E. coli, and alimen
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method to provide physicians the ab
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Standard precautions Hand hygiene
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Eye injury, burn, or abrasion Eye i
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º Bandage wound with sterile dress
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9. C.S. Leedham, C.G. Blood, and C.
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Acronyms AAR AFSOC ANA ANP ANSF ATP
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LMA MEDEVAC MEDCAP MRAP MSL MD MTF
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References Articles F.K. Butler, J.
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