The goals of the Tactical Wilderness Medicine column are to: 1) publish an article every four months about a recent advancement in battlefield trauma care, focusing on TCCC guidelines; 2) discuss the implications for wilderness medicine; and 3) provide any breaking news about TCCC guidelines and other tactical emergency medicine topics.
The WMS has a long history with tactical medicine topics for nearly three decades. It has been a popular topic among members which has led to multiple presentations within annual conferences (preconferences, lectures, workshops), Wilderness Medicine Magazine articles, Wilderness & Environmental Medicine journal publications, and presence as a core topic within the wilderness medicine fellowship program, Academy of Wilderness Medicine. This collaborative effort started in the 1990s with Frank Butler Jr., at the First and the Second World Congresses of Wilderness Medicine, (Butler 2017a) and more recently by Brad L. Bennett et al. at the Seventh World Congress of Wilderness Medicine in 2016. (Bennett et al 2017a) Furthermore, many key TCCC topics are now being coordinated by the WMS Operational Medicine Committee at annual conferences, scheduled to continue at the Winter/Summer 2020/2021 conferences.
TCCC was preceded by the Advanced Trauma Life Support (ATLS) course, which has been the basis of trauma education in the U.S. civilian sector for clinical providers. Many Naval Special Warfare (NSW) corpsmen took ATLS as well as part of their advanced trauma education and training. The limitation of ATLS when applied to battlefield care is that, while it does cover penetrating (e.g., bomb fragmentation and gunshot wounds) trauma, in the early 1990s the primary focus was blunt trauma (e.g., motor vehicle accidents), which was not the most prevalent injury pattern in battlefield trauma. There was no specific NSW curriculum focused on penetrating trauma. TCCC began in 1992 after a NSW Biomedical Research and Development program review of battlefield trauma care. (Butler 2017a) The focus for this research effort was the realization that, although extremity hemorrhage was a leading cause of preventable death in combat casualties, tourniquet use was universally disparaged in both civilian and military out-of-hospital trauma care. After this thorough review of battlefield trauma care, recommendations made resulted in the development of the first set of TCCC Guidelines in 1996 as a set of evidence-based, best-practice trauma care guidelines designed specifically for use on the battlefield. (Butler et al 1996) A number of key leaders within the WMS, who were already established experts on austere medicine, assisted in reviewing the TCCC guidelines for the strength of evidence that supported these recommendations, and discussed their implications for the battlefield and other austere environments. (Butler and Zafren 1998)
After 2001, the lessons learned from the battlefields of Iraq and Afghanistan allowed continuous refinement of the TCCC guidelines through the efforts of the newly created Department of Defense (DoD) Committee on Tactical Combat Casualty Care (CoTCCC). The membership consisted of Army, Navy, Air Force operational physicians, trauma researchers, trauma training specialists, and senior Special Operations medics and corpsmen. (Giebner 2017) Importantly, experienced Army medics, Navy corpsmen, and Air Force pararescuemen are essential members in the CoTCCC since these guidelines are for battlefield tactical application. The members within the CoTCCC serve to monitor and review advances in prehospital care and technology. The committee uses this information to make TCCC guideline updates based upon: 1) ongoing review of published literature; 2) ongoing interaction with combat casualty care research laboratories; 3) direct feedback from experienced medics and corpsmen; 4) input from military lessons learned centers; 5) case reports discuss at weekly Joint Trauma System process improvement video-teleconferences; and 6) expert opinion from both military and civilian trauma experts. (Butler et al 2014)
There are three goals in TCCC: 1) treat the casualty; 2) prevent additional casualties; and 3) complete the mission. To date, TCCC has been well documented to play a major role in achieving the highest casualty survival rate in the history of modern warfare in military units that train their members, no matter what their specialty. (Eastridge et al 2012; Butler 2017b) Specifically, the single most successful TCCC intervention to date is the reintroduction of tourniquet use on the battlefield. (Butler 2017b)
TCCC is presently the standard for battlefield trauma care in the US Military and for many allied nations. CoTCCC members worked closely with civilian trauma colleagues in the Hartford Consensus group and within the White House to translate trauma care lessons learned on the battlefield to lives saved at home that resulted in the development of the course called Stop the Bleed, now sponsored by the American College of Surgeons. (Pons et al 2015; Callaway 2017) In cooperation with the National Association of Emergency Medical Technicians (NAEMT), the CoTCCC has helped to develop a number of TCCC-based trauma courses to assist in training civilian emergency medical services systems, fire and rescue, and law enforcement organizations in trauma care. (Butler 2017) Others have also adopted the TCCC Guidelines for austere trauma care in their civilian organizations. (Callaway 2017; Smith 2017)
The wilderness environment presents some of the same challenges experienced by medics/corpsmen on the battlefield. Both patient and provider are typically in remote locations where evacuation will be neither rapid nor easy; there may be ongoing hazards to contend with; equipment is limited; the environment may be cold, hot, or aquatic; and the providers are often not trauma care specialists. (Butler and Zafren 1998; Sward and Bennett 2014) The incredible diversity of nature that makes the wilderness so alluring complicates the care of the wilderness trauma patient in a myriad of ways, e.g., falls from height, whitewater rescue, high-angle rescue, and avalanche rescue. Although many of these challenges are distinct from those encountered on the battlefield, there is a good deal of overlap in the approach to patient care in these settings. See a recent overview of TCCC recommendations for their applicability to the wilderness environment. (Bennett et al 2017b; Butler et al 2017b)
The primary DoD website for TCCC guidelines, education, training is located at: https://www.deploymentmedicine.com. A short video overview of TCCC can be viewed at: https://www.deployedmedicine.com/market/11/content/79
Others locations for TCCC Guidelines are located at: National Association of Emergency Management Technician (NAEMT), and in the Prehospital Trauma Life Support textbook (Military Version) that is published every 4-5 years by NAEMT. (Butler et al 2014) Once the CoTCCC approves TCCC guideline topics, they are published in the peer-reviewed Journal of Special Operations Medicine.
Featured articles in this Wilderness Medicine Magazine column will be published based on updates to the TCCC guidelines and other tactical medicine considerations for wilderness medicine. Previously, Wilderness Medicine Magazine has published articles on this topic as feature (freestanding) articles, such as our recent article on TCCC Recommended Tourniquet List Update. Tactical medicine articles will cover one of the five categories based on the M-A-R-C-H trauma assessment algorithm:
- Massive hemorrhage (e.g., tourniquets, hemostatic gauzes, etc.)
- Airway control (e.g., i-gel supraglottic airway device)
- Respiratory support (e.g., needle decompression, chest seals)
- Circulation (e.g, shock management with fresh whole blood transfusion, IV tranexamic acid)
- Hypothermia (e.g. active heating hypothermia enclosure kits)
Others are encouraged to submit a paragraph that outlines a tactical medicine topic of interest as it relates to wilderness medicine. Send this outline to the magazine editors for an approval to proceed and after the full article is approved it will be published in this new Wilderness Medicine Magazine Tactical Wilderness Medicine column.
Baker H. What is Wilderness Medicine? Wilderness Environ Med. 1995;6:3-10.
Bennett BL, Butler F, Wedmore I (Guest Editors). Editorial: Tactical Combat Casualty Care Lessons Learned: Transitioned to Other Austere Environments. Wilderness & Environ Med (Special Edition). 2017a;28:S3-S4.
Bennett BL, Butler F, Wedmore I (Guest Editors). Tactical Combat Casualty Care Lessons Learned: Transitioned to Other Austere Environments. Wilderness & Environ Med (Special Edition). 2017b;28:S1-S153.
Bennett BL and Christensen R. Committee on Tactical Combat Casualty Care Updates and Expands Recommended Tourniquet List. Wilderness Medicine Magazine. Volume:36 Issue:3, Summer 2019. https://www.wms.org/magazine/1245/tourniquet Accessed 01 March 2020.
Butler FK. Tactical Combat Casualty Care: Beginnings. Wilderness & Environ Med. (Special Edition). 2017a;28:S3-S4.
Butler FK. TCCC Updates: Two Decades of Saving Lives on the Battlefield: Tactical Combat Casualty Care Turns 20. J Spec Oper Med. 2017b;17(2):166-172.
Butler FK, Zafren K, eds. Tactical management of wilderness casualties in special operations. Wilderness Environ Med. 1998;9(2): 62-117.
Butler FK, Hagmann J, Butler EG. Tactical Combat Casualty Care in Special Operations. Mil Med 1996;161(Suppl):3–16.
Butler FK, Giebner SD, McSwain N, et al, editors. Prehospital trauma life support manual. 8th edition (Military). Burlington (MA): Jones and Bartlett Learning; 2014.
Butler FK, Bennett BL, Wedmore I. Tactical Combat Casualty Care and Wilderness Medicine: Advancing Trauma Care in Austere Environments. Emerg Med Clin North Am. 2017;35(2):391-407.
Callaway D. Translating Tactical Combat Casualty Care Lessons Learned to the High-Threat Civilian Setting: Tactical Emergency Casualty Care and the Hartford Consensus. Wilderness & Environ Med (Special Edition). 2017;28:S140-S145.
Eastridge BJ, Mabry RL, Seguin P, et al. Death on the Battlefield (2001-2011): implications for the future of combat casualty care. J Trauma. 2012;73(Suppl):S431-S437.
Giebner SD. Transition to the Committee on Tactical Combat Casualty Care. Wilderness & Environ Med (Special Edition). 2017;28:S18-S24
Llewellyn C. The Symbiotic relationship between operational military medicine, tactical medicine, and wilderness medicine. Wilderness & Environ Med (Special Edition). 2017;28:S6-S11.
Pons O, Jerome J, McMullen J, et al. The Hartford Consensus on active shooters: implementing the continuum of prehospital trauma response. J Emerg Med 2015;49:878-885.
Smith W. Integration of tactual combat casualty care into the National Park Service. Wilderness & Environ Med (Special Edition). 2017;28:S146-S155.
Sward D, Bennett BL. Wilderness medicine. World J Emerg Med 2014;5:5–15.