Despite the advances in our knowledge of tactical medicine and the incremental advancements in best practice, the battlefield still claims the lives and livelihoods of our brothers- and sisters-in-arms. Better armor, changes in policy, optimization of organized trauma systems, collection of data from battlefield care documentation, enhancement of non-medical first responder care, placement of resuscitative surgery close to the point of injury, and availability of strategic critical care transport have all led to substantial improvements in the care and eventual outcomes of wounded servicemembers. However, compliance at the boots-on-ground level, the medics and corpsmen placing the first dressing, remains shockingly low:
- “Less than half of all eligible combat casualties receive any analgesia at the POI.” (2015)
- “Relatively few patients with open combat wounds receive antibiotic administration as recommended by TCCC guidelines” (2018)
- “Proportions of eligible patients receiving TXA were low despite emphasis in the guidelines” (2017)
- “Most casualties with documented hypotension after trauma in the Prehospital Trauma Registry did not receive prehospital blood or fluid intervention. Of the interventions performed, most did not match with contemporary TCCC guidelines.” (2018)
- “Of patients with a GSW or puncture wound to the chest, 74.2% underwent chest seal placement. Most of the chest seals placed were not vented in accordance with guidelines” (2018)
- “Of the 705 patients within the entire [trauma registry], 118 (16.7%) had documented use of [hemostatic gauze].” (2017)
- “Hemostatic agents were infrequently utilized to manage traumatic hemorrhage during the recent conflicts in Afghanistan and Iraq.” (2018)
- “The [trauma registry] data capture was suboptimal with many patients lacking documentation of vital signs and procedural details.” (2017)
*See the references to all these studies at the bottom of the post.
To Be Clear
We are the best we have ever been. Since 2011 we have slowly started reducing the number of servicemembers dying of potentially survivable wound. We are placing tourniquets appropriately and evacuating casualties quickly. We are even seeing incremental acceptance of newer treatments like TXA. Our combat medics outperform nearly every coalition counterpart in terms of the quality of our treatment. We are good, but we can be excellent.
The TCCC Guidelines are not optional. In March of 2018, the Department of Defense has mandated that all personnel, military and civilian alike, be trained in the appropriate level of TCCC. Before that, the Commander of CENTCOM mandated that anyone setting foot in the CENTCOM area of responsibility be trained in TCCC. Compliance with TCCC is a top-level mandate coming from the highest levels of the military.
The TCCC Guidelines are open source and available to everyone. They are not protected by CAC access or labeled For Official Use Only. They are posted for all to see on the Defense Health Agency’s Deployed Medicine website. Great effort and large amounts of money have been invested to ensure providers everywhere have access to the tools they need to be educated and up-to-date on TCCC.
Why then are we having such a hard time with compliance? I don’t suspect that Specialist Snuffy the platoon medic wakes up every morning and decides to disobey orders from the Pentagon. Nor do I suspect he thinks he knows more about treating combat casualties than the committee of physicians and medics pouring over evidence to update best practice. Where are we going wrong?
Good medics do what they can to ensure their patients don’t bleed out or die of an obstructed airway. Great medics do what they can to set their patients up for success on the operating room table and in the recovery wards later.
Giving TXA, blood, and antibiotics are all basic combat medic tasks, are recommended by the TCCC Guidelines, and will decrease the number and severity of complications down the road. The difference is your patient being able to return to duty versus being permanently disabled, being able to walk or use their hands versus losing too much tissue for the limb to be viable, being able to recognize family and friends versus irreparable neurologic damage from SEPSIS or under-resuscitation.
Thoughts on Compliance
Medically speaking, poor compliance is one of the biggest barriers to good patient care and positive outcomes following disease or injury. Poor compliance with the prescription of medical care leads directly to further disease and disability. Much time and energy have been invested to make medications less complicated to obtain and take. The same effort has been invested in the TCCC guidelines in the form of the Deployed Medicine website by the Defense Health Agency and the Joint Trauma System.
Many medics, especially commissioned leaders and senior NCOs are unaware of the TCCC Guidelines. Many assume TC3 is a one-time course or a box that must be checked prior to deployment. Such assumptions are false and betray a tragic misunderstanding of our chosen profession. Medicine is a science and is constantly being updated as new data are collected. Ignorance of this reality is not an excuse for providing substandard care. There are a wealth of resources posted on the Deployed Medicine website including videos, podcasts, pocket guides, and reference material. There is even a free app for your smartphone (available in whichever app store you use).
The Law of Primacy being what it is, most NCOs will pass along what they were taught in the same manner they were taught it. Unless they have received subsequent training in education or medicine, they will pass along the same myths and misunderstandings they believe in the same sort of oral tradition used by ancient cultures before the advent of books. This is frightfully inadequate and the men and women depending on our expertise have earned more. It is on the shoulders of NCOs to drop their hubris, understand the importance of real science and best practice, and seek the training they need to become technically and tactically competent.
The data show we aren’t good at following directions. We are doing the minimum necessary to deliver living patients to hospitals, but we are skipping steps to ensure they survive to discharge. We are either unaware of the standard or we have chosen to ignore it; either option is unacceptable. There are very few jobs in the military where the pain, suffering, disability, and even death of another servicemember are in your control. Treat your profession with the seriousness it deserves.
- Schauer SG, Robinson JB, Mabry RL, Howard JT. Battlefield Analgesia: TCCC Guidelines Are Not Being Followed. J Spec Oper Med. 2015;15(1)
- Schauer SG, Fisher AD, April MD, Stolper KA, Cunningham CW, Carter R, et al. Prehospital Administration of Antibiotic Prophylaxis for Open Combat Wounds in Afghanistan: 2013-2014. J Spec Oper Med. 2018; 18(2):53-56
- Schauer SG, April MD, Naylor JF, Wiese J, Ryan KL, Fisher AD, Cunningham CW, Mitchell N, Antonacci MA. Prehospital Administration of Tranexamic Acid by Ground Forces in Afghanistan: The Prehospital Trauma Registry Experience. J Spec Oper Med. 2017; 17(3):55-58
- Schauer SG, Naylor JF, April MD, Fisher AD, Cunningham CW, Fernandez JRD, Shreve BP, Bebarta VS. Prehospital Resuscitation Performed on Hypotensive Trauma Patients in Afghanistan: The Prehospital Trauma Registry Experience. Mil Med; [ahead of print]
- Schauer SG, April MD, Fisher AD, Cunningham CW, Gurney J. Junctional Tourniquet Use During Combat Operations in Afghanistan: The Prehospital Trauma Registry Experience. J Spec Oper Med. 2018; 18(2):71-74
- Schauer SG, April MD, Naylor JF, Simon EM, Fisher AD, Cunningham CW, Morissette DM, Fernandez JRD, Ryan KL. Chest Seal Placement for Penetrating Chest Wounds by Prehospital Ground Forces in Afghanistan. J Spec Oper Med. 2017; 17(3):85-89
- Schauer SG, April MD, Naylor JF, Fisher AD, Cunningham CW, Ryan KL, Thomas KC, Brillhart DB, Fernandez JRD, Antonacci MA. QuikClot® Combat Gauze® Use by Ground Forces in Afghanistan The Prehospital Trauma Registry Experience. J Spec Oper Med. 2017;17(2):101-106
- Schauer SG, April MD, Naylor JF, Maddry JK, Arana AA, Dubick MA, Fisher AD, Cunningham CW, Pusateri AE. Prehospital Application of Hemostatic Agents in Iraq and Afghanistan. Prehosp Emerg Care. 2018;22(5):614-623
- Schauer SG, April MD, Naylor JF, Oliver JJ, Cunningham CW, Fisher AD, Kotwal RS. A descriptive analysis of data from the Department of Defense Joint Trauma System Prehospital Trauma Registry. US Army Med Dep J. 2017;(3):92-97