Different Trauma Requires Different Care Strategies •It is intuitive that combat and civilian trauma are different, BUT… •It is difficult to devise and implement needed changes. •No one of medical professionals has all of the necessary skills and experience. •Trauma docs and combat medical personnel have different skill sets. Both are needed to optimize battlefield trauma care strategies. •Tourniquets are one striking example of how battlefield trauma care has sometimes been slow to change. TCCC principles are now determined by physicians and combat medical personnel working as a team. In the past, the failure of these two groups to communicate well slowed the implementation of critical trauma care measures. We will look at a dramatic example of this. Tourniquets in WWII Wolff AMEDD J April 1945 “We believe that the tourniquet in common use is ineffective in most instances under field conditions…it rarely controls bleeding no matter how tightly applied.” This report was written by an Army doctor in World War II. Provided very clear input on tourniquets. A tourniquet seem to be a simple thing to fix. Now, fast-forward 25 years. Vietnam Over 2500 deaths occurred in Vietnam secondary to hemorrhage from extremity wounds. casualties had no other injuries. 25 later, we had still not learned the tourniquet lesson in Vietnam. 2500 preventable deaths from extremity hemorrhage were the result. Surely, we would have learned the lesson after this experience. Maybe not - fast-forward another 25 years.
Tactical Combat Casualty Care in Special Operations Military Medicine Supplement August 1996 Trauma care guidelines customized for the battlefield In the mid-90s, the Special Operations medical community began looking for some better answers for combat trauma and Tactical Combat Casualty Care was born. TCCC •Originally a Special Operations research effort •Trauma management plans that take into account the unique challenges faced by combat medical personnel •Now used throughout U.S. military and by most allied countries •TCCC has helped U.S. combat forces to achieve the highest casualty survival rate in history. Although TCCC started in Special Ops, it is now used by all services in the U.S. military, conventional as well as Special Ops. It has proved dramatically successful in the Global War on Terrorism. TCCC has been a major factor in U.S. forces having the highest casualty survival rate in our history. TCCC Approach •Identify the causes of preventable death on the battlefield •Address them aggressively •Combine good medicine with good tactics Picture is the border How People Die in Ground Combat (From COL Ron Bellamy) 9% KIA – Exsanguination from Extremity Wounds 5% KIA – Tension Pneumothorax 1% KIA – Airway Obstruction This depicts a study that was done on Soldiers who died in Vietnam. We can use this data to help us understand what types of injuries are seen in combat and which may or may not be survivable.
Committee on Tactical Combat Casualty Care •The prehospital arm of the Joint Trauma System •42 members from all services in the DoD and civilian sector •Trauma Surgeons, ER and Critical Care physicians, operational physicians; medical educators; combat medics, corpsmen, and PJs •Nearly 100% deployed experience •Meet periodically; update TCCC as needed Read text. TCCC Now: Additional Interventions Hemostatic dressings Intraosseous infusion devices Hypotensive resuscitation Fentanyl lozenges for severe pain Ketamine as an analgesic option Junctional hemorrhage control devices Tranexamic Acid (TXA) Cric-Key for surgical airways Hypothermia prevention Management of wounded hostile combatants are more recent changes in the TCCC guidelines made by the CoTCCC. Note that the updated guidelines are now published with each new edition of the Military version of Prehospital Trauma Life Support textbook. The recommendations made in this text have the endorsement of the American College of Surgeons Committee on Trauma and the National Association of EMTs. TCCC is the ONLY set of combat trauma care guidelines to have been approved by these two groups. TCCC: How Do We Know That it’s Working? Read text.
Mabry and McManus AMEDD Center and School “The new concept of Tactical Combat Casualty Care has revolutionized the management of combat casualties in the prehospital tactical setting.” Critical Care Medicine July 2008 In 2008, Major Bob Mabry was the Director of Academics for Combat Medic Training at the Army Medical Department Center and School. He used to be an 18D Special Forces medic himself. LTC John McManus was the Director of Predeployment Medical Training for the Army Medical Department Center and School. USMC Casualty Scenario 2008 • CoTCCC gets input directly from combat medics, corpsmen, and USAF pararescuemen (PJs) • 15 casualties - 4 tourniquets applied • 3 lives saved - 4th casualty died from chest wound In every meeting of the CoTCCC, real combat casualty scenarios are presented and discussed. Lessons learned are incorporated into TCCC curriculum. Tourniquets – et al: Two Landmark Papers • Published in 2008/2009 • Tourniquets are saving lives on the battlefield • 31 lives saved in 6 months by tourniquets • Author estimates 2000 lives saved with tourniquets in this conflict up to that date (2009) • No arms or legs lost because of tourniquet use Most important tourniquet papers ever published Most importantly – apply tourniquets ASAP when needed. Survival improved if shock prevented. NOBODY is arguing about whether tourniquets save lives any more.