Tactical Combat Casualty Care in Operation Iraqi Freedom

U.S. Army Medical Department Journal, April-June, 2005 by Michael J. Tarpey

Introduction

In the mid-1990s, the U.S. Army Special Operations Command developed a new set of guidelines concerning the treatment of casualties on the battlefield. These guidelines, called Tactical Combat Casualty Care (TCCC), have been updated since their initial proposal and have been widely practiced with excellent results throughout the Special Operations community. (1) However, there has been very, little spread of the use of the TCCC guidelines into conventional units. This article reviews the use of the principles of TCCC by a mechanized infantry unit in Operation Iraqi Freedom One (OIF 1).

Background

When Task Force (TF) I-15 Infantry (TF 1-I5 IN), part of the Third Brigade Combat Team of the third Infantry Division, deployed to Kuwait in Jan 03 in preparation for war, I was assigned by the Professional Officer Filler System (PROFIS) as their Battalion Surgeon. While the infantrymen were training over the next several months for urban combat, trench warfare, and long-range movement, our medical platoon simultaneously underwent a rigorous train-up in preparation for combat. First Lieutenant Robert (Brian) Fox, the battalion physician assistant (PA), SFC Christopher Parker, the medical platoon sergeant, our other medical noncommissioned officers (NCOs) and I concentrated on teaching our 38 enlisted medics the principles of TCCC. Brietly, TCCC breaks up battlefield medicine into three stages:

* "Care Under Fire" is care rendered by the medic on the battlefield while under hostile fire with an aid bag as the only equipment.

* "Tactical Field Care" is treatment provided once the casualty and his unit are no longer under hostile fire, with equipment limited to that carried into the field.

* "Combat Casualty, Evaluation Care" (CASEVAC) is treatment provided once the casualty has been picked up by aircraft, vehicle, or boat.

The training of medics by the battalion surgeon and PA, together with the medical NCOs, is probably the most important job assigned to these professionals. However, it is frequently overlooked or not done well. This is particularly true for health care providers who normally work in hospitals and are assigned as PROFIS health care providers just prior to deployment. Despite the inherent difficulties, assigned health care providers have to make the training of medics their first priority. Health care providers who normally work in hospital settings will need to make a concerted effort in their training to get out of the Advanced Trauma Life Suppott (ATLS) mindset and into one based around battlefield medicine, with its completely different scenarios. Intense daily training is the best way to accomplish this.

Health care providers assigned to Level I positions, such as a Battalion Aid Station (BAS), have a particularly important role to play since up to 90% of combat deaths occur on the battlefield before a casualty ever reaches a medical treatment facility. (2) Hemorrhage from wounds remains the number one cause of mortality, accounting for 50% of all deaths. (3) In Vietnam, 50% of combat deaths were due to wounds with uncontrolled bleeding, with about 11% of these in sites accessible by first aid treatment. (3,4) Ryan et al assert that approximately one-third of all killed in action (KIA) could potentially be salvageable and point to data from Oman in 1973 and Panama in 1989 in which the stationing of emergency medicine physicians at casualty collection points close to the point of wounding resulted in lower KIA rates than in previous conflicts. (5-7)

With this in mind we undertook to train our medics and ourselves in the precepts of TCCC with the goal of lowering battlefield morbidity and mortality. Were concentrated first and foremost on the importance of stopping hemorrhage promptly and efficiently with the use of tourniquets. We also reviewed again and again various battlefield procedures such as needle decompression of tension pneumothorax, nasopharyngeal airway insertion, and cricothyrotomy. The medics worked on starting intravenous (IVs) in all kinds of conditions, including in the dark with night vision goggles.

Emphasis was placed on the simple recognition and treatment of common battlefield injuries. For instance, medics were trained to recognize shock by assessing pulses and mental status, rather than with blood pressure cuffs and stethoscopes which have little use on the battlefield. The principles of hypotensive resuscitation were reviewed, as well as in what situations the judicious use of IV fluids was appropriate. We avoided teaching, procedures like endotracheal intubation and CPR which are of little use to frontline medics in combat.

Each of the medics, alone and in teams, was run through repeated reality-based combat scenarios featuring other Soldiers acting as casualties with the types of wounds likely to be encountered on the battlefield. The medics learned to quickly triage casualties first, then going through the actual steps involved in their treatment. Again and again they were made to demonstrate the actual steps involved in each medical procedure. In addition, we talked through various scenarios, especially those encountered by medics in Mogadishu in 1993. Given the likelihood of impending war at that time, it was not difficult to get 100% effort from the medics in their training. By the time our unit moved north, we had reviewed these techniques and scenarios with our medics so many times that recognition and treatment at times, simply involved muscle memory, which is important in the stress of combat.