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Oct 09

Tactical Combat Casualty Care & Evidence Based Medicine: The Good, The Bad, The Irrelevant (Part II)

 

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

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  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.
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  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.
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  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.
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  31. Trunkey DD: Is ALS necessary for pre-hospital trauma care (editorial)? J Trauma 1984; 24: 86-7.
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  33. Baker MS: Advanced trauma Life Support: Is It Adequate Stand-Alone Training for Military Medicine? Milit Med 1994; 159: 587-90.
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  45. National Association of Emergency Medical Technicians.  Prehospital Trauma Life Support. 7th military ed. St Louis, MO: Mosby; 2011
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  54. 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
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TCCC and Evidence Based Medicine

This is a two part podcast with Dr. Daved VanStralen discussing the topic of evidence based medicine and TCCC. We have taught and "preached" TCCC for over a decade, while defending the guidelines, equipment, and recommendations with the "mantra" evidence-based medicine. After years of unexplained failures and issues, we take a look at what "EBM" actually is, and whether its performance parameters are relevant to your operational parameters.
Please check out the podcast page at elementrescue.com for additional information, research, and links.


 
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