IMPORTANT ASPECTS OF TACTICAL COMBAT CASUALTY CARE
You may have heard me reference something called “TCCC” in previous articles, podcasts, or videos. TCCC, sometimes called T3C or T triple C, is a term that means Tactical Combat Casualty Care. It represents the recommendations with regards to prehospital care of soldiers who have incurred traumatic injuries on the battlefield. Established in the mid-1990s, TCCC guidelines have become so widely accepted that many law enforcement and civilian medical personnel have adopted them.
And well they should. These protocols were developed at the cost of painful lessons in the field in Iraq and Afghanistan. It is thought that there were 1000 preventable deaths in these conflicts. If you add civilian injuries during the same time period, the number of preventable deaths might number in the hundreds of thousands. The TCCC’s primary goals is to save lives, prevent additional casualties, and, in true military fashion, complete the mission.
There are three “zones” or “phases” of care defined by TCCC. These zones provide guidance on the appropriate actions that will aid the injured while taking into account the safety of the medic. The three phases include:
Care Under Fire: During this phase, the medic and, if possible, the mentally alert casualty must continue to actively engage the enemy. Fire superiority is the best medicine to prevent further injuries to casualties (and further casualties). Your goal in this situation is get your victim out of the line of fire or, say, a vehicle that is on fire and to treat life-threatening hemorrhage, all while not getting killed yourself. While under fire, it’s recommended to use tourniquets as the method of choice where possible, placing it high and tight on the damaged extremity, as the circumstances (they’re shooting at you) don’t usually allow a thorough evaluation of the anatomy. Most other interventions should be delayed until the casualty can be moved to a more secure position. Once you’ve accomplished this, you move on to the next phase: Tactical Field Care.
Tactical Field Care: Once the immediate threat to the medic and patient have been neutralized and a secure perimeter has been established, the medic can institute a higher level of emergency care, often referred to as Advanced Life Support (ALS).
ALS may just involve placing an IV line, but surgical intervention may be needed to establish, say, an airway. During this phase, the medic would also work to seal sucking chest trauma, treat a tension pneumothorax, bandage wounds, splint fractures, prevent hypothermia, and treat shock.
Tactical Evacuation (TACEVAC): This phase focuses on transporting the casualty to higher medical resources for definitive care.
It pays to remember the mnemonic M.A.R.C.H./P.A.W.S. MARCH is a concept well-known to many preparedness folk; it is essentially your primary survey, but what is PAWS? PAWS becomes your secondary survey. Briefly, here’s what MARCH and PAWS stand for:
M Massive Hemorrhage: Establish, continue, or improve the control of life-threatening bleeding by whatever means necessary. Tourniquets, hemostatic agents, pressure dressings, pelvic binders, and more.
A Airway: Establish and maintain a reliable airway via chin lift, jaw thrust, recovery position, nasal airways, and other devices or procedures.
R Respiration: Seal open chest wounds, decompress tension pneumothoraxes, and ventilate to assure oxygen gets to the lungs. This may be through a bag-valve mask and include the use of oxygen if available. In modern times, trained professionals may even intubate a casualty.
C Circulation: Administer IV fluids to treat shock. This may involve giving blood or other related products.
H Hypothermia: Remove wet clothing, cover with blankets, and establish a barrier between the cold ground and the victim. Some also use H to stand for “head”: treatment of traumatic brain injuries.
Once you’ve evaluated and treated the issues addressed in MARCH, it’s times to survey PAWS:
P Pain management
A Antibiotics for early prevention of infection
W Wound reassessment and care
S Splinting fractures and providing stabilization to limb dressings.
In survival settings, you can’t duplicate the care given at a field hospital or a trauma center. Your final outcomes won’t always be happy. You might, however, use some of the methods in MARCH/PAWS to possibly save the life of those who would otherwise die during or in the aftermath of a disaster. I’ll be going over some of these individually in future articles.
Before I finish, I’d like to thank the authors who contribute to the Journal of Special Operations Medicine, whose efforts allow us to continually adjust TCCC guidelines to save more military, law enforcement, and civilian lives in these troubled times.
Joe Alton MD
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