Page 101 - JSOM Winter 2025

thereby obtaining a reality check on the nascent TCCC recom- COL John Kragh, an orthopedic surgeon working at the Ibn Sina
mendations by those who would actually be responsible for im- hospital in Baghdad, documented that 31 lives were saved with
plementing them. tourniquets at his hospital in Ibn Sina, Iraq, in one 6-month period
(Butler 2017 – TCCC Turns 20, Kragh 2013, Kragh 2009, Kragh
The second step in changing the culture in battlefield trauma care, 2008). This finding, when extrapolated to all U.S. casualties sus-
and the one that was responsible for the initial spread of TCCC tained in Iraq and Afghanistan up to that point in time, indicated
beyond the few early adopters, was the first preventable death that, as early as 2008, well over 1,000 U.S. service members’ lives
review of U.S. fatalities from Iraq and Afghanistan. When U.S. had likely been saved with tourniquets. This extraordinary reduc-
forces invaded Afghanistan in 2001, there was no Joint Trauma tion in preventable death was obtained without loss of limbs due
System in the U.S. military and no systematic review of combat to tourniquet ischemia. COL Kragh’s work irrefutably confirmed
casualty care outcomes in the U.S. military to look for opportu- the lifesaving benefit of extremity tourniquets, an intervention
nities to improve care (Butler 2015 – Preserving Our Advances). that was perhaps the single most controversial aspect of TCCC
In 2004, the U.S. Special Operations Command (USSOCOM) had when the original paper was published in 1996 (Butler 2017 –
two critically important questions that needed to be answered: TCCC Turns 20, Butler 1996).
1) what, specifically, were the causes of death in Special Op-
erations forces who had died as a result of combat wounds in The sixth event was the information that became available in 2012
those conflicts; and 2) what, if anything, might have been done that documented the difference between the preventable death
to prevent those deaths? One might reasonably assume that the rates in units using TCCC in contrast to units that were not nec-
Department of Defense had always performed preventable death essarily using TCCC. After ten years of combat operations in Iraq
reviews on its combat fatalities, but, as of 2004, that was not the and Afghanistan by the 75th Ranger Regiment, Kotwal and his
case. USSOCOM called upon COL John Holcomb, then the Com- colleagues reported only one potentially preventable death among
mander of the U.S. Army Institute of Surgical Research, to help an- 32 combat fatalities (out of 419 casualties) sustained by the 75th
swer these questions. COL Holcomb’s team found that in Special Rangers (Kotwal 2011), and that death occurred in the hospital,
Operations forces, 15% of combat deaths resulted from injuries not the prehospital, setting. This finding stands in compelling
that were potentially survivable, and a number of those deaths contrast to the 15% to 28% incidence of potentially preventable
might have been prevented with simple TCCC measures such as a deaths reported in other studies of U.S. casualties in these conflicts
tourniquet (Holcomb 2007). The findings of that study provided (Eastridge 2012, Kelly 2008, Holcomb 2007). When considering
a clear signal that TCCC training and equipment was needed only the prehospital phase of care, potentially preventable deaths
throughout the Special Operations community. Also needed was a among fatalities in the 75th Rangers was zero as compared to 24%
methodology for an ongoing evaluation of the impact of these new in the study by Eastridge et al. (2012). This remarkable disparity
battlefield trauma care techniques on morbidity and mortality. in potentially preventable deaths between early adopters of TCCC
and the rest of the U.S. military was not widely known until the
The third event that led to the widespread adoption of TCCC con- Kotwal and Eastridge studies were published in 2011 and 2012,
cepts was a U.S. Central Command message that required that all respectively. These observed differences in potentially preventable
combatants deploying to that theater be equipped with a tourni- deaths may be due in part to differences in the methodology of
quet and a hemostatic dressing (USCCENTCOM Message 2005). determining which deaths are considered potentially preventable
This requirement was driven by the CENTCOM Surgeon at the or differences between the casualty cohorts reported. Those points
time, then-Colonel Doug Robb. Although the services have the notwithstanding, there is little to no disagreement at present that
primary responsibility for training and equipping combatants, this the interventions pioneered by TCCC produced a marked reduc-
mandate from Central Command forced supervising medical offi- tion in preventable deaths in the prehospital phase of combat ca-
cers throughout the services to rethink their many years of medical sualty care – the phase of care during which combat fatalities are
training that had consistently taught that them that the use of ex- most likely to occur (Butler 2017, Berwick 2016, Dickey 2015).
tremity tourniquets was an ill-advised idea.
The seventh key step in changing the culture of the U.S. military to
The fourth landmark event in changing the culture on battle- incorporate TCCC as a standard was effective strategic messaging.
field trauma care also resulted from a collaboration between The success of the TCCC Transition Initiative, COL Kragh’s find-
USSOCOM and USAISR. After the documentation of prevent- ings on tourniquets, and the decreased incidence of preventable
able deaths in the Holcomb study, the leadership of USSOCOM deaths in units that were early TCCC adopters were presented
supported and funded the TCCC Transition Initiative, which ex- at military medical conferences and in the published medical and
pedited TCCC equipping and training of deploying USSOCOM lay literature (Kragh 2009, Kragh 2008, Mabry 2008, Sohn 2007,
units. The project was led by an 18-D Special Forces medic, SFC Beekley 2007, Holcomb 2006, Bottoms 2006, Tarpey 2005, Butler
Dominic Greydanus, and not only provided TCCC training and 2005 – TCCC TI). This steady stream of favorable evidence re-
equipment to deploying Special Operations units, but also col- garding TCCC both increased awareness among combat medical
lected feedback from medics, corpsmen, and PJs when these units personnel and their physician/physician assistant supervisors of
returned from combat operations. In addition, this program pro- the success of TCCC in reducing preventable deaths and provided
vided early documentation of the success of TCCC interventions unit medical officers with published evidence that they could pres-
(Butler 2017 – TCCC Turns 20, Butler 2017 – TCCC LLL, Butler ent to their unit commanders when seeking to implement TCCC
2005 – TCCC TI). The USAISR preventable death project, which in their units (Butler 2017, Eastridge 2012, Kotwal 2011).
had produced usable information on Special Operations fatali-
ties by early 2005, even though it was not published until several Finally, the TCCC experience has made it abundantly clear that
years later, and the early results of the TCCC Transition initiative, a necessary component of advances in battlefield trauma care is
prompted the U.S. Special Operations Command to mandate in combat line commander attention and advocacy. Evidence alone is
March of 2005 that TCCC principles be used in caring for combat often not sufficient to drive advances in trauma care (Butler 2017
casualties and that all U.S. Special Operations Command com- – TCCC LLL). Multiple challenges inherent in effecting change in
ponent commands begin training and equipping their forces in battlefield trauma care in the U.S. military have been identified
TCCC (Brown 2005, USSOCOM msg 2005). (Butler 2015 – Preserving our Advances, Mabry 2014).
The fifth key step that helped to change the culture of battlefield The divided lines of authority and distributed responsibilities in
trauma care in the U.S. military was the documentation of the the military structure make it difficult to develop and implement
lifesaving impact of extremity tourniquet use. It is often difficult such advances throughout the Department of Defense (Mabry
to identify with precision which elements of TCCC are responsi- 2014). Butler, Smith, and Carmona described the potential barri-
ble for lives saved, but tourniquets are an exception. The work of ers to change in this way (Butler 2015 – Preserving our Advances).

Introduction to Tactical Combat Casualty Care | 99