Addressing preventable death remains the holy grail of trauma care. Be it the ‘Golden Hour’ or the ‘Platinum Ten Minutes,’ all trauma guidelines and training in some way are designed with the goal in mind of preventing the death of otherwise survivable victims. Prior to 1996, US military combat medics were trained to treat the injured on the battlefield according to the concepts of Advanced Trauma Life Support (ATLS), a standardized approach to trauma care that is still considered to be the standard of care for the in-hospital Emergency Department management of trauma. However, after several years of anecdotal concerns, it became apparent that the tenets of ATLS were not developed for combat medics, but for physicians operating from a resource rich fixed facility. The medical management principles were based off the assumption that hospital diagnostic and therapeutic equipment were available and, most importantly, ATLS did not account for the existence of the tactical combat environment. There was no provision or allowance for the commonalities of combat such as incoming fire, darkness, environmental extremes, casualty transportation problems, long delays to definitive care, and the need to balance the management of casualties while continuing the combat mission. Thus, the conflict between operational reality and ATLS medical principles was not addressed, forcing combat medical personnel to make real-time battlefield adjustments to the civilian trauma guidelines with little more than limited anecdotal experience.
In 1996, after a multi-year Special Operations medical research project to improving combat trauma outcomes, Captain Frank Butler, Lt. Colonel John Hagmann, and Ensign George Butler published a landmark paper in a supplement to the August 1996 journal Military Medicine that introduced the concept of tactical combat casualty care (TCCC) as a guideline customized for use on the battlefield to address preventable causes of combat death by optimizing care rendered prior to arrival to a fixed medical facility. Based on extensive research of military autopsy and wounding data, there were several innovations proposed in the paper, the most important being the recognition of the need in battle to rectify both good tactics AND good medicine. “Corpsmen and medics must be aware of the fact that good medicine can sometimes be bad tactics and that bad tactics can get everyone killed or cause the mission to fail.” The TCCC guidelines were quickly adopted by the US Navy Special Operations and Army Special Forces communities, and soon thereafter began to be accepted in other military units. Since then, numerous reports and studies have been published in the medical literature documenting that the doctrine and practice of TCCC significantly improves battlefield morbidity and mortality. In a Defense Health Board memo on 6 August 2009, it was noted that, in several special operations units where all members were trained in TCCC, there were no reported incidents of preventable battlefield fatalities during the entirety of their combat operations. TCCC guidelines have been credited with reducing the case fatality rate (CFR) in current combat operations from approximately 14% in Vietnam to 9.2-9.6% during OIF/OEF. Given such effectiveness, TCCC is now taught and practiced throughout many levels and branches of the military, and is recommended training by the Defense Health Board for all deploying combatants and medical department personnel. The tri-service Committee on TCCC (CoTCCC) was founded in 2001 as a body of experts with the mission of maintaining and updating the TCCC guidelines, ensuring new technologies and information were incorporated on an ongoing basis.
Over the past few years, a strong partnership developed between CoTCCC, the American College of Surgeons Committee on Trauma, and the Prehospital Trauma Life Support Executive Council; this lead to the development of a military edition of PHTLS which focused on TCCC principles. Along with the development and delivery of PHTLS TCCC courses, the published success of TCCC in reducing combat mortality, and the return of many combatants to civilian first responder work, this PHTLS manual has made many federal and civilian agencies aware of TCCC. OF course, this knowledge and implementation of TCCC guidelines into civilian practice is most ubiquitous in the law enforcement field. However, as TCCC medical data has been published in more traditional civilian emergency medicine and trauma journals, it is increasingly being applied in routine civilian emergency response protocols under the justification that the wounding patterns and austerity of many civilian settings are similar to combat.
Federal and civilian tactical and emergency medical response teams now stand at the same crossroads the military special operations medical community stood at in the early 1990s. Implementing TCCC guidelines as written into civilian protocols has the same fundamental flaws as utilizing civilian ATLS principles for battlefield treatment of combat wounded. This practice is essentially basing medical care on a doctrine designed to address the specific environment and restrictions of the military battlefield, not the civilian setting. TCCC is written for the combat medic operating in a combat theater, not for the civilian tactical medic operating in a crack house in downtown Washington, DC. There is no doubt that the weapons and wounds are similar between the two settings, and there is no doubt that federal and civilian tactical teams are indeed in combat. But, just as ATLS did not address many of the unique factors specific to the military combat environment, TCCC does not address the differences in the military setting, the federal or civilian provider, and the non-military environment.
These differences include, but are not limited to, the following:
● Scope of practice and liability
○ Federal and civilian medical responders must practice under State and local scope of practice and protocols, and are subject to both negligence and liability that the military provider is not.
● Patient population to include geriatrics and pediatrics
○ TCCC data and research was heavily based off of a 18-30 year old population, not all age groups as represented in civilian operations.
○ TCCC was written primary to address the wounded combatant and does not address high threat care for innocent non-combatants.
● Distance, time required, resources available for evacuation to definitive care
○ Most civilian cities have multiple definitive medical facilities, many with Level 1 Trauma centers, within short distance.
○ Ground and air medical assets are readily available in most civilian and federal settings.
● Differences in barriers to evacuation and care
○ In civilian settings, there is far less need for concern for secondary hits or armed resistance to evacuation. In general, once clear of the immediate scene, security in the civilian setting can be assumed.
● Baseline health of the population
○ The TCCC combatant population is relatively healthy and physically fit without the high incidence of chronic medical illness that exists in the civilian population.
● Wounding patterns
○ Although the weapons are similar between military and civilian scenarios, the wounding patterns differ given the prevalence of and differences in protective ballistic gear, as well as the use of and strength of improvised explosive devices in the military setting.
● Chronic medication use in the injured
○ TCCC fails to account for and address the effects of chronic medication use, such as beta blockers and especially anti-coagulants.
● Special populations including pregnant patients, mentally and physically handicapped
○ Special populations are prevalent in the civilian setting and the required differences in their care should not be a battlefield adjustment.
The conclusion, logically then, is that blind implementation of TCCC doctrine by federal and civilian first responders without consideration for these subtle differences will result in a practice that will not be as effective and potentially may be detrimental in some populations.
Similar to what TCCC did for the medical care in the military combat setting, civilian and federal first responders needed a new paradigm, a framework that defined the environment and resource constraints, and provided guidance that would allow best evidence-based management of patients to accomplish the life-saving mission. To address this need, a diverse group of first responder experts called the Committee for Tactical Emergency Casualty Care (C-TECC) was formed and, in May 2011, held their inaugural meeting to create the Tactical Emergency Casualty Care guidelines (TECC). The TECC guidelines are a set of best practice recommendations for casualty management during high threat civilian tactical and rescue operations. Based upon the principles of Tactical Combat Casualty Care (TCCC), TECC guidelines account for differences in the civilian environment, resources allocation, patient population, and scope of practice.
Modeled after the Committee for Tactical Combat Casualty Care, C-TECC is comprised of a broad range of interagency operational and academic leaders in the practice of high threat medicine and fire/rescue from across the nation, including members from emergency medicine, emergency medical services, police, fire, and the military special operations community. It is the responsibility of C-TECC to maintain and update the TECC guidelines, incorporating new information and technology and reflecting the best evidenced-based medicine principles. C-TECC remains an independent civilian entity but maintains a close relationship with CoTCCC for guidance and support.
- The goals of Tactical Emergency Casualty Care include the following:
- To balance the threat, civilian scope of practice, differences in civilian population, medical equipment limits, and variable resources for response to atypical emergencies
- To establish a framework that balances risk:benefit ratio for all civilian operational medical response
- To provide guidance on medical management of preventable deaths at or near the point of wounding
- To miminize provider risk while maximizing patient benefit
The applications of the TECC guidelines for civilian Fire/EMS medical operations are far reaching, beyond just the traditional application in tactical and law enforcement operations. The medical response to almost any civilian scenario involving high risk to responders, austere environments, or atypical hazards will benefit from the guidelines, including active shooter response, CBRNE and Terrorism related events, mass casualty, wilderness/austere scenarios, technical rescue events, and even traditional trauma response.