Managing combat trauma on the modern battlefield represents challenges that are scarcely encountered within the civilian community. The advent of tactical combat casualty care (TCCC) represented a fundamental paradigm shift from the care of casualties (CAX) that evolved in the late 1970s. Special operations forces (SOF) engaged in combat operations, removed from conventional forces (CF) and with austere logistical support, represent a set of unique challenges, as well. The limited amount of equipment and medical supplies, coupled with delays in evacuation, add to what is already a frightening experience. Being wounded also generates great fear and anxiety in the CAX. Special operations medics, exposed to hostile fire while caring for CAX, become likely targets, resulting in the special operations medic unintentionally becoming “part of the problem, not the solution” and forcing CAX to care for themselves. The conditions associated with this type of environment demand specialized training for all SOF. We refer to this specialized training as SOF combat casualty care.
The foundations of SOF combat casualty care began with the Advanced Trauma Life Support (ATLS) Training Program. ATLS was established after a tragic plane crash in 1976 in rural Nebraska, which devastated an entire family. The pilot, an orthopedic surgeon, was seriously injured, while his wife was killed instantly. Three of his four children sustained critical injuries. This physician had to flag down a passing motorist to transport his children to the nearest hospital. Upon arrival, he found the small rural hospital locked. Even after the hospital was opened and a physician was called in, he found the emergency care provided at the regional hospital inadequate and often inappropriate. Once he returned to work, the physician, with assistance from advanced cardiac life support (ACLS) personnel and the Lincoln Medical Education Foundation, began to collate a set of protocols for the management of such patients and produced the initial framework for the national ATLS course. These protocols were adopted by the American College of Surgeons (ACS) Committee on Trauma (COT) in 1980.
The original intentions of the ATLS courses, modeled on the ACLS program, were to train physicians and nurses who did not manage trauma routinely in the initial management of the severely injured patient. Several changes in the standard protocols used to treat trauma CAX were modified. Previously, a complete evaluation was performed; a diagnosis was made; and only then, was the casualty treated. The new approach was to establish a protocol to assess then treat the most life-threatening injuries first, and accordingly, move on to the next injury. The “ABCs” of trauma was established to prioritize the order of assessment and treatment. Nothing new was added; current evaluation procedures were simply reorganized to reduce morbidity and mortality in the “golden hour” of trauma. The ATLS pilot courses were introduced in Auburn, Nebraska in 1977. By 1980, these courses expanded nationally under the auspices of the ACS. Early reports on the implementation and evaluation of these pilot courses and the improvements in civilian trauma care appeared in the literature soon afterward.
Since that time, ATLS has been accepted as the standard of care for the first hour of trauma management and taught to both military and civilian providers. In 1981, shortly after the development of the ATLS course, the ACS/COT and the National Association of Emergency Medical Technicians entered into a cooperative agreement to develop an ATLS course for prehospital providers. This course was appropriately named Prehospital Trauma Life Support (PHTLS). The first PHTLS course was taught in New Orleans in 1984. PHTLS is nationally endorsed and widely adopted as a continuing educational program by hospitals, educational institutions, emergency medical service agencies, and military medical programs and is incorporated into many initial and refresher emergency medical technician/emergency medical technician–paramedic courses.
Until recently, U.S military medical personnel were trained to care for combat CAX using the principles put forth in the ATLS model. The inappropriateness of many of these measures when applied to combat CAX initiated the TCCC project by the U.S. Naval Special Warfare Command and was continued by the United States Special Operations Command (USSOCOM). USSOCOM developed a new set of tactically appropriate battlefield trauma management guidelines in 1996. These guidelines focus primarily on the most common causes of preventable death on the battlefield and the most protective measures that can be reasonably performed in combat, taking the special operations tactical environment and the unique patterns and types of wounds into consideration while developing casualty management recommendations.
TCCC guidelines, used in special operations since 1998, have proven successful in combat operations. In 2001, USSOCOM recognized the need to update these guidelines, and based on research conducted by the Naval Operational Medical Institute, a Committee on Tactical Combat Casualty Care (CoTCCC) was established. This committee updated the TCCC guidelines in 2003 and republished them in the revised PHTLS manual, 5th edition.
CoTCCC is an ongoing project conducted under the sponsorship of the Navy Bureau of Medicine and Surgery. The unique aspect of this joint organization is that it includes special operations personnel, including special forces medics, Navy SEAL corpsmen, Air Force pararescuemen, trauma surgeons, emergency medicine physicians, anesthesiologists, and medical educators, who collaborate to continually update TCCC guidelines. TCCC was established as the standard of care for special operations medic training in 2005. TCCC equipment and training also became mandatory for all deploying SOF, as the first responder to a wounded special operations warfighter on the battlefield is often not a special operations medic. Since World War II and the war in Vietnam much of the decline of combatants killed in action (KIA) can be attributed to TCCC training, techniques, and equipment.
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