Battlefield medicine

Tactical combat casualty care is becoming the standard of care for the tactical management of combat casualties within the Department of Defense and is the sole standard of care endorsed by both the American College of Surgeons and the National Association of EMT's for casualty management in tactical environments.[10]

Tactical combat casualty care is built around three definitive phases of casualty care:

1. Care Under Fire: Care rendered at the scene of the injury while both the medic and the casualty are under hostile fire. Available medical equipment is limited to that carried by each operator and the medic. This stage focuses on a quick assessment, and placing a tourniquet on any major bleed.
2. Tactical Field Care: Rendered once the casualty is no longer under hostile fire. Medical equipment is still limited to that carried into the field by mission personnel. Time prior to evacuation may range from a few minutes to many hours. Care here may include advanced airway treatment, IV therapy, etc. The treatment rendered varies depending on the skill level of the provider as well as the supplies available. This is when a corpsman/medic will make a triage and evacuation decision.
3. Tactical Evacuation Care (TACEVAC): Rendered while the casualty is evacuated to a higher echelon of care. Any additional personnel and medical equipment pre-staged in these assets will be available during this phase.[11][12]

Since "90% of combat deaths occur on the battlefield before the casualty ever reaches a medical treatment facility" (Col. Ron Bellamy) TCCC focuses training on major hemorrhaging and airway complications such as a tension-pneumothorax. This has driven the casualty fatality rate down to less than 9%.[13][11]

Listed below are interventions that a TCCC provider may be expected to perform depending on the phase of TCCC they are at and their level of training. This list is not comprehensive and may be subject to change with future revisions in TCCC guidelines.

Hemorrhage control interventions include the use of extremity tourniquets, junctional tourniquets, trauma dressings, wound packing with compressed gauze and hemostatic dressings, and direct pressure.[14] Newer devices approved for use by the CoTCCC for hemorrhage control include the iTClamp and XStat.[15] Pharmacological options also include tranexamic acid, and hemostatic agents such as zeolite and chitosan.[14]

In managing a casualty’s airway, a TCCC provider may position the casualty in the recovery position or utilize airway adjuncts such as nasopharyngeal airways, oropharyngeal airways, and supraglottic airways.[16] They may also utilize the jaw thrust and head-tilt/ chin-lift maneuver to open a casualty's airway.[16] Advanced TCCC providers may also perform endotracheal intubation and cricothyroidotomy.[16]

Respiratory management largely revolves around the use of chest seals, vented and unvented, and needle decompressions to manage tension pneumothoraxes.[16]

In circulation management a TCCC provider may obtain intravenous/ intraosseous access for the administration of fluids such as normal saline, lactated Ringer’s solution, whole blood, and colloids and plasma substitutes for fluid resuscitation.[17][18] This also provides a route for the administration of other drugs in accordance with the provider’s scope of practice.[18]

Head injuries would indicate for cervical spine immobilization to the best of the provider’s abilities if deemed appropriate in a given setting, or the use of devices such as a cervical collar.[19]

As trauma-induced hypothermia is a leading cause of battlefield deaths, a provider may also perform hypothermia prevention can be accomplished through the use of a Hypothermia Prevention and Management Kit or emergency blanket, the placement of a casualty on an insulated surface, and the removal of wet clothing from a casualty’s body.[20]

Care under fire is care provided at the point of injury immediately upon wounding while the casualty and care provider remain under effective hostile fire.[21] The casualty should be encouraged to provide self-aid and continue remain engaged in the firefight if possible.[22] If unable to do so, the casualty should be encouraged to move behind cover or "play dead".[22] Due to the high risk of injury to the care-provider and limited resources at this phase, care provided to the casualty should be limited to controlling life-threatening hemorrhage with tourniquets and preventing airway obstruction by placing casualty in the recovery position.[23] The primary focus during care under fire should be winning the firefight to prevent further casualties and further wounding of existing casualties.[23]

Tactical field care phase begins when the casualty and care-provider are no longer under imminent threat of injury by hostile actions.[21] Though the level of danger is lessened, care-providers should exercise caution and maintain good situational awareness as the tactical situation may be fluid and subject to change. The tactical field care phase enables the provision of more comprehensive care according to care providers' levels of training, tactical considerations, and available resources.[21] Major tasks that are to be completed in the tactical field care phase include the rapid trauma survey, the triage of all casualties, and the transport decision.[21]

Tactical evacuation care refers to care provided when a casualty is being evacuated and en-route to higher levels of medical care.[21] Care providers at this phase are at even less risk of imminent harm as result of hostile actions.[21] Due to improved access to resources and the tactical situation, more advanced interventions can be provided to casualties such as endotracheal intubation.[21] Patient re-assessments and the addressing of issues that were not or were inadequately addressed previously are also major components of this phase.[21]

In tactical evacuation (TACEVAC), casualties are moved from a hostile environment to a safer and more secure location to receive advanced medical care. Tactical evacuation techniques use a combination of air, ground and water units to conduct the mission depending on the location of the incident and medical centres. Ground vehicle evacuations are more prevalent in urban locations that are in close proximity to medical facilities.[24] Requests for evacuation of casualties and pertinent information are typically communicated through 9-Line MEDEVAC and MIST reports.[25]

Tactical evaluation is an umbrella term that encompasses both medical evacuation (MEDEVAC) and casualty evacuation (CASEVAC). Medical evacuation platforms are typically not engaged in combat except in self-defence and defence of patients.[26] MEDEVAC takes place using special dedicated medical assets marked with a red cross. Casualty evacuation is through non-medical platforms and may include a Quick-Reaction force aided by air support.[24]

For aircraft involved TACEVAC situations there are many considerations that need to be accounted for. Firstly, the flying rules vary widely depending on the aircraft and units in play.[24] The list of determinants to create the TACEVAC strategy include the distances and altitudes involved, time of day, passenger capacity, hostile threat, availability of medical equipment/personnel, and icing conditions.[24] As mentioned TACEVAC is more advanced than TCCC, it also includes training to/for:[24]

• improve breathing [24]
• provide supplemental oxygen [24]
• administer Tranexamic acid (TXA) [24]
• deal with traumatic brain injuries [24]
• fluid resuscitation[24]
• blood product administration[24]
• blood transfusion[24]
• preventing and treating hypothermia[24]

There are three levels of tactical combat casualty care providers in the Canadian Armed Forces.

Every soldier receives a two-day combat first aid training course. The course focuses on treating hemorrhages, using tourniquets and applying dressings, and basic training for casualty management.[23]

A select number of soldiers are chosen to participate in an intense 2-week tactical combat casualty care course where soldiers are provided with additional training.[23] Overall, they are trained to work as medic extenders since they work under the direction of medics.

The tactical medicine (TACMED) course is offered exclusively to medics. The tactical medicine program provides training for advanced tactical combat casualty care and is the highest level of care provided by the Canadian Armed Forces in a battlefield setting.[23] Medics are trained to treat and manage patients using the MARCHE protocol.[23] The MARCHE protocol prioritizes potential preventable causes of death in warfare as follows:

1. Massive hemorrhage control[23]
2. Airway management[23]
3. Respiratory management[23]
4. Circulation[23]
   1. Bleeding control[23]
   2. Intravenous (IV)/ intraosseous (IO) access[23]
   3. Fluid resuscitation[23]
   4. Tourniquet reassessment[23]
5. Hypothermia prevention[23]
6. Head injuries[23]
7. Eye injuries[23]
8. Everything else[23]
   1. Monitor patient[23]
   2. Pain management[23]
   3. Head-to-toe assessment[23]
   4. Address all wounds found[23]
   5. Antibiotics[23]
   6. Tactical evacuation preparation[23]
   7. Documentation of care and findings[23]

Care under fire happens at the point of injury. According to tactical combat casualty care guidelines, the most effective way to reduce further morbidity and mortality is to return fire at enemy combatants by all personnel.[27] The priority is to continue the combat mission, gain fire superiority, and then treat casualties.[27] The only medical treatment rendered in care under fire is the application of direct pressure on massive bleeding.[27] Tactical combat casualty care recommends a tourniquet as the single most important treatment at the point of injury.[27] It is recommended during care under fire to quickly place tourniquets over clothing, high, and tight; the tourniquet should be reassessed when out of danger in the tactical field care phase.[27]

Tactical field care is considered to be the backbone of Tactical Combat Casualty Care and consists of care rendered by first responders or prehospital medical personnel while still in the tactical environment.[28] The acronyms MARCH and PAWS help personnel remember crucial treatment steps while under duress.

The MARCH acronym is used by personnel to remember the proper order of treatment for casualties.

Massive hemorrhage. The most potentially survivable cause of death is hemorrhage from extremity bleeds, however more than 90% of 4596 combat mortalities post September 11, 2001 died of hemorrhage associated injuries.[27] It is recommended to apply a Committee on Tactical Combat Casualty Care (CoTCCC) approved tourniquet for any life-threatening extremity hemorrhages.[27] Tourniquets during tactical field care should be placed under clothing 2 to 3 inches above the wound, with application time written on the tourniquet.[27]

Airway. Non-patent or closed airway is another survivable cause of death. Airway injuries typically occur due to inhalation burns or maxillofacial trauma.[27] If a person is conscious and speaking they have a patent open airway, while nasopharyngeal airway could benefit those who are unconscious and breathing.[27] However, unconscious casualties who are not breathing could require surgical cricothyroidotomy, as endotracheal intubation is highly difficult in tactical settings.[27]

Respirations. Tension pneumothorax (PTX) develops when air trapped in the chest cavity displaces functional lung tissue and puts pressure on the heart causing cardiac arrest.[27] Thus, open chest wounds must be sealed using a vented chest seal.[27] Tension pneumothorax should be decompressed using a needle chest decompression (NCD) with a 14 gauge, 3.25 inch needle with a catheter.[27] Ventilation and/or oxygenation should be supported as required.[27]

Circulation. It is more important to stem the flow of bleeding than to infuse fluids, and only casualties in shock or those who need intravenous (IV) medications should have IV access.[27] Signs of shock include unconsciousness or altered mental status, and/or abnormal radial pulse.[27] IV should be applied using an 18 gauge catheter and saline lock in tactical field care, secured by transparent would-dressing film.[27] Tranexamic acid (TXA) should be given as soon as possible to casualties in or at risk of hemorrhagic shock.[27] An intraosseous (IO) device could also be used for administering fluids if IV access is not feasible.[27]

Head injury/hypothermia. Secondary brain injury is worsened by hypotension (systolic blood pressure under 90 mmHg), hypoxia (peripheral capillary oxygen saturation under 90%), and hypothermia (whole body temperature below 95 Fahrenheit or 35 Celsius).[27] Medical personnel can use the Military Acute Concussion Evaluation (MACE), while non-medical personnel can use the alert, verbal, pain, unresponsive (AVPU) scale to identify traumatic brain injury.[27] The "lethal triad" is a combination of hypothermia, acidosis, and coagulopathy in trauma patients.[27] Since hypothermia can occur regardless of ambient temperature due to blood loss, the Hypothermia Prevention and Management Kit (HPMK) is recommended for all casualties.[27]

The PAWS acronym is used by personnel to remember additional casualty care items that should be addressed.

Pain. Proper management of pain reduces stress on a casualty's mind and body, and have reduced incidents of post-traumatic stress disorder (PTSD).[27] Pain management is shown to reduce harmful patient movement, improves compliance and cooperation, and allows for easier transport as well as improved health outcomes.[27]

Antibiotics. All battlefield wounds are considered contaminated, and thus any penetrating injury should receive antibiotics at the point of injury as well as in tactical field care.[27] The recommended parenteral antibiotics are 1g ertapenem or 2g cefotetan, which can treat multi drug-resistant bacteria.[27] if the casualty can tolerate oral fluids, 400mg moxifloxacin can be administered orally instead of ertapenem or cefotetan.[27]

Wounds. Assessing the casualty for additional wounds improves morbidity and mortality. First responders must address burns, open fractures, facial trauma, amputation dressings, and security of tourniquets.[27] Prior to movement, reassessment of wounds and interventions is very important. Casualties with penetrating trauma to the chest or abdomen should receive priority evacuation due to the possibility of internal hemorrhage.[27]

Splinting. Explosions (such as from improvised explosive device or land mines) that cause lower extremity traumatic amputation cause forces to move upward through the body, which may cause further bone disruption, hollow organ collapse, or internal bleeding.[27] Thus, first responders should use the Combat Ready Clamp (CRoC), the Junctional Emergency Treatment Tool (JETT), or the SAM Junctional Tourniquet to control junctional hemorrhage and stabilize the pelvis.[27] In cases of penetrative eye trauma, responders should first perform a rapid field test of visual acuity, then tape a rigid shield over the eye to prevent further damage, and also give 400mg oral moxifloxacin as soon as possible.[27] Pressure must never by applied to an eye suspected of penetrative injury.[27]