Page 103 - JSOM Winter 2025

Sohn VY, Miller JP, Koeller CA, et al. From the combat medic to the achieved with no loss of limbs among U.S. casualties in Iraq or Af-
forward surgical team: the Madigan model for improving trauma ghanistan due to tourniquet use (Butler 2015 – US Mil Hx, Kragh
readiness of brigade combat teams fighting the Global War on Ter- 2009, Kragh 2008).
ror. J Surg Res. 2007;138(1):25–31. doi:10.1016/j.jss.2006.09.006
Tarpey M. Tactical combat casualty care in Operation Iraqi Freedom. As documented by Col (ret) John Kragh and others, limb tourni-
U.S. Army Medical Department Journal. 2005;April–June:38–41. quets have proven remarkably effective at saving lives in casualties
U.S. Central Command Message: Tourniquets and Hemostatic Dress- with extremity hemorrhage, with very few complications (Kragh
ings. Date/Time Group 061715Z January 2005. 2013, Eastridge 2012, Caravalho 2011, Kragh 2009, Kragh 2008,
U.S. Special Operations Command message: Tactical Combat Casu- Mabry 2008). The strategic messaging regarding tourniquets that
alty Care Training and Equipment. Date/Time Group 222016Z drove the spread of TCCC from the Special Operations commu-
March 05, 2005. nity to the conventional military units included reports of prevent-
able death from extremity hemorrhage when tourniquets should
Battlefield Experience with TCCC in Iraq and Afghanistan have been used but weren’t (Kelly 2008, Beekley 2008, Holcomb
As noted previously, at the beginning of the war in Afghanistan, 2007) and documentation of improved survival as the use of ex-
TCCC was used only by Navy SEALs, the 75th Ranger Regiment, tremity tourniquets became more prevalent (Kragh 2013, Eas-
the Army Special Missions Unit, Air Force pararescuemen, and tridge 2012, Kotwal 2011, Caravalho 2011, Savage 2011, Kragh
a few other innovative units in the U.S. military (Butler 2017 – 2009, Kragh 2008, Mabry 2008, Tien 2008, Tarpey 2005, Butler
TCCC Turns 20, Kotwal 2011, Butler 2007, Tarpey 2005, Pappas 2005-TCCC TI).
2001, Malish 1999).
A landmark study published in 2012 by COL Brian Eastridge and
MSG Ted Westmoreland, one of the senior enlisted medics in the his co-authors examined the causes of death for all 4,596 U.S.
Army Special Missions Unit, accumulated extensive experience military combat deaths that occurred between October 2001 and
using TCCC to treat combat casualties in the first few months of June 2011. They used autopsy data to judge whether deaths were
the conflict in Afghanistan. In a presentation to the Special Opera- potentially preventable had optimal treatment been provided
tions Medical Association in December 2005, he made the follow- ( Eastridge 2012). Their findings included: 1) 87% of combat-
ing recommendation: “Implement TCCC into all service medical related deaths occurred in the prehospital setting; 2) 24% of pre-
training NOW.” (Westmoreland 2005). hospital deaths were potentially preventable; and 3) hemorrhage
was the cause of 91% of the preventable deaths on the battlefield.
The impact of this limited use of TCCC was not well- appreciated Additionally, the Eastridge study enabled a comparison of the in-
until the first preventable death analysis was conducted by the cidence of death from extremity hemorrhage between the early
U.S. military in Afghanistan as a combined effort of the U.S. Spe- years of the wars in Iraq and Afghanistan—when tourniquets
cial Operations Command, the U.S. Army Institute of Surgical were not issued to or used by—most of the U.S. Military, and the
Research, and the Armed Forces Medical Examiner System. That later years of the war when the TCCC-led use of tourniquets had
study, led by COL John Holcomb, examined the first 82 Special
Operations fatalities in Iraq and Afghanistan (Holcomb 2007). become widespread throughout U.S. forces. The drop in prevent-
The study found that 8 of the 12 individuals who died from com- able death from extremity hemorrhage between these two periods
was striking. In 2014, Davis noted that: “Tourniquets have been
bat injuries that were potentially survivable might have been saved the signature success in battlefield trauma care in Afghanistan and
simply by the proper application of TCCC principles.
Iraq. Based on the work of Army COL John Kragh and colleagues,
One of the key factors that was responsible for the eventual adop- the number of lives saved from this intervention has been esti-
tion of TCCC throughout the U.S. military was the early experi- mated to be between 1,000 and 2,000.” (Davis 2014).
ence with limb tourniquets in Afghanistan and Iraq. Tourniquets Other TCCC recommendations such as moving away from large
were a high-visibility issue for two reasons: the first is that tourni- volume crystalloid fluid resuscitation for casualties in hemor-
quet use as recommended by the original 1996 TCCC Guidelines rhagic shock, using nasopharyngeal airways instead of endotra-
was a radical departure from prehospital trauma care practice – cheal tubes in TFC, and using needle decompression instead of
both military and civilian – as it existed 25 years ago, At that chest tubes for the initial treatment of suspected tension pneu-
time, tourniquet use was strongly discouraged (Butler 1996). mothorax were proven effective as well. These recommendations
The second is that ubiquitous tourniquet use has clearly been the also helped to reduce both the medical equipment load carried by
single most important lifesaving battlefield trauma care advance combat medical personnel (Butler 2017 – TCCC Turns 20, Butler
achieved during the wars in Iraq and Afghanistan (Butler 2017 –
TCCC LLL, Butler 2015 – US Mil Exp with TQ, Davis 2014). 2007 – Evolving concepts).
U.S. military personnel deployed initially to Afghanistan and Numerous reports published in the medical literature and col-
Iraq without commercially manufactured tourniquets, but they lected from combat first responders in that period documented
now routinely carry well-made, effective tourniquets into combat that TCCC saved lives on the battlefield of Iraq and Afghanistan
( Butler 2015 – US Mil Hx). and improved the tactical flow of missions on which casualties
have been sustained. Tarpey described the use of TCCC by ele-
In 2003–2006, the preventable death review done by Kelly found ments of the Third Infantry Division in the initial phase of the
a 7.8% incidence of death either solely or significantly due to ex- war in Iraq. He reported that: “The adoption and implementation
tremity hemorrhage. (Kelly 2008). This incidence of preventable of the principles of TCCC by the medical platoon of Task Force
death approximates the 7.4% incidence of preventable death from 1-15 in OIF 1 resulted in overwhelming success. In over 25 days
extremity hemorrhage seen in the Vietnam conflict. (Maughon of continuous combat with 32 friendly casualties, many of them
1970).
serious, we had 0 Killed in Action and 0 Died of Wounds, while
After the use of tourniquets became widespread, beginning in simultaneously caring for a significant number of Iraqi civilian
2005 in Special Operations and then spreading to conventional and military casualties.” (Tarpey 2005).
forces in the ensuing years, deaths from extremity hemorrhage Gresham noted that the 101st Airborne Division, “by teaching and
dropped dramatically (Butler 2015- US Mil Hx, Eastridge 2012). using (TCCC) ideas, has achieved one of the highest casualty sur-
By 2018, based on ongoing surveillance by the JTS weekly trauma vival rates in combat of any unit in the Army.” (Gresham 2006).
teleconferences and the monthly JTS/AFMES teleconferences,
deaths from isolated extremity hemorrhage had become virtually In an article in “Tip of the Spear,” the official publication of the U.S.
non-existent. When shock from extremity hemorrhage did occur, Special Operations Command, Bottoms stated that: “Multiple re-
it was usually the result of the tactical exigencies of the battle- ports from SOF First Responders have credited TCCC techniques
field. This reduction of mortality from extremity hemorrhage was and equipment with saving lives on the battlefield.” (Bottoms

Introduction to Tactical Combat Casualty Care | 101