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corpsmen assigned to Marine units, Ranger medics, Special Forces including Tactical Combat Casualty Care. If the recommended
18-D medics, Air Force pararescuemen (PJs), Air Force aviation TCCC combat trauma management plan doesn’t work for the
medics, and Coast Guard health specialists. Physician membership specific tactical situation that a combat medic, corpsman, or PJ
included representatives from the trauma surgery, emergency med- encounters, then care must be modified to best fit the tactical sit-
icine, critical care, and operational medicine communities. Physi- uation. Scenario-based planning is critical for success in TCCC
cian assistants, medical planners, and medical educators were also (Butler 2022, Butler 2021, Butler 2001, Butler 1996).
represented (Butler 2017, TCCC LLL).
References
In 2007, due to the increasing visibility and success of TCCC in Butler FK, Burkholder T, Chernenko M, et al. Tactical combat casu-
the Global War on Terrorism (GWOT), the Navy Medical Support alty care maritime scenario: shipboard missile strike. J Spec Oper
Command proposed that the CoTCCC be moved to a more senior Med. 2022;22(2):9–28. doi:10.55460/ZT9J-EI8Z
joint command. This proposal was briefed to the offices of the Butler FK Jr, Littlejohn LF, Byrne TC, Martino E, Montgomery HR,
Assistant Secretary of Defense for Health Affairs and the Surgeon Drew B. Tactical combat casualty care scenario: management of
for the Joint Chiefs of Staff. Subsequently, in March 2008, the a gunshot wound to the chest in a combat swimmer. J Spec Oper
CoTCCC was relocated to function as a working group of the Med. 2021;21(3):138–142. doi:10.55460/5A31-WYTH
Trauma and Injury Subcommittee of the Defense Health Board Butler FK. Two decades of saving lives on the battlefield: tactical com-
(DHB) (Butler 2017 – TCCC Turns 20). The DHB is chartered bat casualty care turns 20. Mil Med. 2017;182 (3):e1563–e1568.
to provide independent advice and recommendations on medical doi:10.7205/MILMED-D-16-00214
issues to the Secretary of Defense through the Under Secretary Butler FK. Leadership Lessons Learned in Tactical Combat Casualty
of Defense for Personnel and Readiness and the Assistant Secre- Care. J Trauma Acute Care Surg. 2017;82(6S Suppl 1):S16–S25.
tary of Defense for Health Affairs, including recommendations doi:10.1097/TA.0000000000001424
regarding the care of U.S. service members wounded in combat Butler FK Jr, Blackbourne LH, Gross KR. The combat medic aid bag:
operations. Five years later, on 21 February 2013, by Direction 2025. CoTCCC top ten recommended battlefield trauma care re-
of the Acting Undersecretary of Defense for Personnel and Read- search, development, and evaluation priorities for 2015. J Spec
iness, the CoTCCC was moved once more, this time to the Joint Oper Med. 2015;15(4):7–19. doi:10.55460/5G8Q-R379
Trauma System (JTS) to have it co-located with other components Butler FK Jr. Tactical medicine training for SEAL mission command-
ers. Mil Med. 2001;166(7):625–631.
of the DoD’s joint combat trauma expertise (Butler – 2017 TCCC Butler FK Jr, Hagmann J, Butler EG. Tactical Combat Casualty Care
Turns 20). In 2017, Congress made the JTS the DoD’s lead agency in Special Operations. Mil Med. 1996;161 Suppl:3–16. doi:10.
for trauma, and the CoTCCC is the prehospital component of 1007/978-3-319-56780-8_1
the Joint Trauma System’s Defense Committee on Trauma (Public Public Law 114-328, 2017. Accessed 18 November 2021. https://
Law 114-328, 2017). www.govinfo.gov/content/pkg/PLAW-114publ328/html/PLAW-
Since 2001, and throughout these organizational changes, the 114publ328.htm
CoTCCC has continued to monitor developments in prehospi-
tal trauma care. The TCCC Guidelines are updated based upon: Changing the U.S. Military Culture in
(1) an ongoing review of the published civilian and military pre- Battlefield Trauma Care
hospital trauma literature; (2) ongoing interaction with military At the onset of hostilities in Afghanistan in 2001, there were only
combat casualty care research laboratories; (3) direct input from a select few units using TCCC. Adoption of TCCC required a
experienced combat corpsmen, medics, and PJs; (4) input from move away from longstanding and firmly entrenched approaches
the service medical Lessons Learned Centers; (5) case reports dis- to battlefield trauma care. How did this transformation in battle-
cussed at the weekly JTS process improvement video-teleconfer- field trauma care in the U.S. military come about? As noted previ-
ences; (6) observations on the causes of death in combat fatalities ously, the Navy SEAL teams and the 75th Ranger Regiment began
gleaned from the monthly JTS-Armed Forces Medical Examiner training all combatants in TCCC prior to the start of the conflicts
System (AFMES) teleconferences; and (7) expert opinion from in Afghanistan and Iraq. The Army Special Missions Unit and the
both military and civilian trauma experts (Butler 2017 – TCCC Air Force Special Tactics and Pararescue communities also imple-
LLL, Butler 2015 – Combat Medic Aid Bag). mented TCCC from in the 1997–1998 time frame and quickly
adopted the practice of teaching TCCC to every combatant so that
Each change to the TCCC Guidelines is now supported by a the most critical life-saving interventions, such as tourniquet ap-
change paper published in the Journal of Special Operations Med- plication, could be accomplished by every one of their unit mem-
icine. Guideline changes are also included in each revision of the bers (Butler 2017 – Beginnings, Kotwal 2011, Pennardt 2009).
PHTLS textbook (Butler 2017 – TCCC LLL, Butler 2015 – Com-
bat Medic Aid Bag). The current version of the TCCC Guidelines The transformation of TCCC use from the few early adopters to
is also maintained on both the Defense Health Agency’s Deployed being used throughout the DoD resulted from a specific sequence
Medicine website as well as the NAEMT website. of events that has been well documented but is not widely known.
How did this culture change in the U.S. Military finally come
As the use of TCCC spread from the U.S. Military to other agen- about?
cies within the Federal government, to allied nations, and to the
civilian sector, it became important to include representatives The first and most fundamental requirement for changing the cul-
from these groups in the TCCC update process, both to secure ture in battlefield trauma care was to provide a higher quality
the benefit of their input and to facilitate communication between set of recommendations. There were several aspects of the TCCC
them and the CoTCCC. Accordingly, the CoTCCC began to invite development process that enabled these improved recommenda-
liaison members from these groups to participate in its combat tions (Butler 2017 – TCCC Turns 20, Butler 2017 – Beginnings,
trauma care performance improvement process. The CoTCCC Butler 2017-TCCC LLL). During the research effort that led to the
voting members and CoTCCC liaison members collectively com- development of TCCC, existing recommendations for prehospital
prise the TCCC Working Group and it is through the untiring combat trauma care were held to the same standards of evidence
efforts of this group that the TCCC Guidelines and other TCCC as those applied to proposed changes to that regimen. Next, as
knowledge products have remained as the state of the art through opposed to simply adopting a civilian-oriented standard of care,
20 years of armed conflict (Butler 2017 – TCCC Turns 20, Butler the actual conditions that combat medical personnel encounter
2017 – TCCC LLL). on the battlefield were considered in developing the new recom-
mendations. Finally, input from combat medics, corpsmen, and
Although the TCCC Guidelines are evidence-based, best-prac- PJs, our country’s primary battlefield trauma care providers, was
tice, trauma care guidelines customized for use on the battlefield, sought and heeded throughout the TCCC development process,
they are guidelines only. There are no rigid protocols in combat,

98 | JSOM Volume 25, Edition 4 / Winter 2025