1. Tactical Combat Casualty Care
Charles W. Beadling, MD, FAAFP, IDHA, DMCC
Center for Disaster and Humanitarian Assistance Medicine
Department of Military and Emergency Medicine
Uniformed Services University
PART I
I spent most of my time not in the hospital in SOF units. As a consequence, I sometimes unknowingly liberally use colorful language or expletives. If I offend anyone in so doing, please tell me you are offended. I will make every effort not to do so again. This is a 2-sided coin. I will remind you of breeches in etiquette, and I hope that you will do the same of me and any of my fellow instructors.

2. AGENDA Objectives Tactical vs. Civilian Trauma Care
Mortality in Combat
Stages of Tactical Care
Tactics, Techniques
and Procedures (TTPs)

3. Learning Objectives
Students will compare and contrast the differences between civilian and tactical trauma.
The student will evaluate the importance of this unique body of knowledge (TCCC) that can decrease the KIA rate in modern warfare.
Last Bullet Bushmaster

4. Learning Objectives Know the three phases of care
Identify the top three causes of preventable combat mortality
List three methods of controlling hemorrhage in the field
Outline additional equipment and skills available with evacuation assets

5. Perform the CORRECT Intervention at the CORRECT Time
Bottom Line
Perform the CORRECT Intervention at the CORRECT Time

6. 70% Blunt Trauma
Same since 1950s when everyone started getting cars

7. Advanced Trauma Life Support
Advantages
Widely accepted in US and internationally
The standard of care in civilian hospitals
Limitations in Combat
Intended for Advanced HCPs
Assumes availability of hospital diagnostic and therapeutic equipment
Assumes immediate surgical capability
Instructor Narrative:
The course was not Not intended for combat medics
Assumes availability of hospital diagnostic and therapeutic equipment (x-rays, labs, etc)
Assumes virtually unlimited resources
No tactical context (austere/hostile environment, limited supply, limited vis, widely variable evacuation times)
So what was/is happening is individual Battalion Surgeons, PA’s and Medics would pick and choose certain treatment plans that they thought were the best. The result: varied levels of care on the battlefield which impacts evacuation and logistics. The bottom Line: Units operating at different levels of competency yet possess the same mission profile.

8. The Problem:
ATLS was never designed or intended to be used in the tactical environment.
Instructor Narrative:
The Problem is ATLS was not designed to be used in the combat environment. WHY?

9. Prior to TCCC Combat Fatalities
90% die before reaching MTF
Identify a problem. Could use MDMP to come up with an answer

10. Tactical Combat Casualty Care (TCCC)
Epidemiology of Trauma
Tactical Environment
Equipment and Tactics
Techniques & Procedures
Significance to YOU
TTP - tactics, techniques, and procedures
Initially a concept. Now, there are numerous articles, retrospective analysis, trauma registries and case reports to support the theory.
Bottom line: It is NOW evidence based medicine.
*Graphic Photo Content*

11. Causes of Combat Wounds
<6% Blunt trauma; therefore, ATLS sucks for this demographic!
Frags are NOT new. TC3 is new
(WWI, WWII, Korea, Vietnam, Middle East)

12. Combat Morbidity & Mortality
Those that will survive regardless
Those that will die regardless
Those who will die from preventable deaths unless the proper life saving steps are taken immediately
Combat Morbidity & Mortality

13. Killed in Action (86% KIA)
Combat Mortality
Killed in Action (86% KIA)
versus
Died of Wounds (12% DOW)
Why are you showing us this slide for the 10th time. Difference b/t KIA and DOW. This is why recent stat showing DOW increasing. We are keeping them alive on the battlefield and they are dying of complications

14. Who has not seen this slide or graphic prior. It was published in 1987
Who has not seen this slide or graphic prior. It was published in Check that persons for breathing and a pulse
If I was in your seat I would be asking why is this training important to me, the HCP? What makes this training any different than other medical training I have received? The answer is we have studied how people die in combat and how that relates to our tactical missions.
By depressing the enter key bring up the circles.
a) 9% of all deaths are bleeding to death from extremity wounds
b) 5% of all deaths are tension pneumothorax (air in the chest that causes a problem)
c) 1% of all deaths are airway obstruction due to facial trauma around the mouth
3) So what does this mean? Next slide
Hancock has a similar slide with different numbers. This was created in 1987 and was the data that gave birth to TCCC. I hope it has changed.

15. So What?
Understand Epidemiology = Develop Appropriate Critical Skill Sets
Understand Environment = Modify Skill Sets/Equipment to Maximize Benefit
Equipment
Training
Research
Skill Set that is arguably simpler than the 2 days of ATLS that you just finished!
Who was this design for – not you. But, you need to know it. Who is going to teach it to that POI medic? Who is going to continue the research that the Baltimore Sun thinks isn’t happening every day at multiple sites to include this University.
So What? – You have to be able to tell Robert Little that he is a flippin’ idiot.

16. Causes of Death on the Modern Battlefield: Oct 01-Nov 04, n=495

17. How Can I Make a Difference?
Exanguinating extremity wounds – 61%
Tension pneumothorax – 33%
Airway obstruction – 6%
Causes of PREVENTABLE combat death
Differnet way of looking at the numbers

18. Critical Tasks Control Hemorrhage Open/Maintain Airway
Decompress a Tension Pneumothorax
Seal Open Chest Wound
Initiate Treatment for Shock
Employ Hypothermia Prevention
XABC
XABC
Some sources will even say CBA (exanquination, PTX, Airway) – based on 9%, 5%, 1%
Seal the chest wound, how? 4 sides
Simplicity is the key. Equipment required to execute the plan must be simple, light, and rugged.

19. TCCC Stages Of Care Care Under Fire Tactical Field Care
Combat Casualty Evacuation Care
One time this may have been restricted to the medic, tech, or corpsman. No longer a linear battlefield. You are no longer “in the rear with the gear”. Now very well could be you!

20. Care Under Fire

21. Care Under Fire
Care rendered at the scene of the injury while rescuer and casualty are still under effective hostile fire.
First action: Return Fire!
Your no good, if you are DEAD

22. Care Under Fire Return Fire/Gain Fire Superiority Devise Rescue Plan
Direct Conscious Casualty in Self Aid (SABA)
Aggressive Hemorrhage Control
Tourniquet
Airway?
C-spine?
If casualty is unable to move and unresponsive, the casualty is likely beyond help.
Have him come to you. Not worth CMH (Casket with Metal Handles)
Rescue plan
Potential risk:benefits
assets - covering fire, screening, shielding, rescue equipment
Everyone (including the pt) understands the plan and movement technique
Fastest Method - two person drag
Other carries- fireman care, one person drag, two person carry, two person fore and aft, Seal team three carry
Other methods- litter, SKED or Stokes (advantage when litter must be raised or lowered more than 10 ft)
C-spine 1.4% of penetrating NECK trauma will have a C-spine injury.

23. 60% Extremity Hemorrhage
Why so much Extremity trauma = body armor
This picture is from OIF. This individual died of a gunshot wound to the leg. This is his only wound!!!
His death could have been prevented by simply applying a tourniquet to his extremity.
Over 2500 deaths in Vietnam were due to extremity hemorrhage. Death due to extremity hemorrhage has been the number one cause of PREVENTABLE death on the battlefield since Korea, perhaps earlier.
Confederate General Albert Sydney Johnston was killed at the battle of Shiloh from a single gunshot wound to his popliteal artery. He bled to death without thinking to use the tourniquet in his pocket. (2006, Welling, Burris, and Hutton)
* The answer has been staring us in the face forever. We are just now seeing it.
60% Extremity Hemorrhage

24. Effective Tourniquets Save Lives
Lived

25. CAT Every soldier, marine, and SOF service member deploys with this.
At one time in Civilian literature “tourniquet” was a dirty word. But, numerous EBM reports documenting its success and low likelihood of complications.
1) Israeli study not using CAT showed 78% overall success. 94% UE. 71% LE. 5.5% peripheral neuropathy. Zero case of ischemic limb necrosis
2) 31 CSH “44 casualties arriving at their facility for whom the CAT was life saving
Once again = EBM
(Transition) Is it perfect? No!

26. CAT Limitations Improper training
Use when severe bleeding is not present
Loosening the device to allow intermittent return of blood flow
Not applying it tight enough
Removing it prematurely
Grenade is a simple device; but, I wouldn’t advice using one without a little training.
Put a 2nd one on!
Loosen it. If blood, crank it back on.

27. Airway Obstruction
This Soldier sustained a single gunshot wound to the jaw. He was held down and multiple failed attempts at intubation were attempted. He became unconscious, was transported on his back, and died from a blocked airway (blood and tongue in the back of his throat). On autopsy, his airway was intact below the throat.
What might have saved him? Simple positioning or possibly a surgical cric.

28. One simple Maneuver