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a robust dialogue with civilian trauma care experts and from the that the lack of an approved FDA indication for fentanyl lozenges
NAEMT educational infrastructure (Butler 2017 – TCCC LLL, and ketamine as analgesics for acute pain does not preclude them
Goforth 2016). from being the best-practice options based on the available clinical
evidence.
Another of the earliest and most productive of the partnerships
formed by TCCC with civilian medical organizations was that be- References
tween TCCC and the Wilderness Medical Society. The wilderness American College of Emergency Physicians. Out-of-Hospital Use of
environment is similar in some respects to the battlefield. In both Analgesia and Sedation. Ann Emerg Med. 2016;67(2):305–306.
settings, the patient and the care provider are often in remote lo- doi:10.1016/j.annemergmed.2015.12.014
cations where evacuation may be delayed and complicated, signif- American College of Emergency Physicians. Out-of-hospital severe
icant and ongoing hazard may be present during the time that care hemorrhage control. Policy Statement. Ann Emerg Med. 2015 Dec;
is being provided, the equipment available for treatment is very 66(6):693. doi:10.1016/j.annemergmed.2015.08.022
limited, the environments may be extreme, and those providing Bennett BL, Butler FK Jr, Wedmore IS. Tactical combat casualty
care are often not paramedics, emergency physicians, or trauma care: transitioning battlefield lessons learned to other austere en-
surgeons (Butler 2017 – Adv Trauma Care in Austere Env, Ben- vironments. Wilderness Environ Med. 2017;28(2 suppl):S3–S4.
nett 2017). The overlap in the austerities of the combat and the doi:10.1016/j.wem.2017.01.003
wilderness settings has resulted in collaboration between military Bulger EM, Snyder D, Schoelles K, et al. An evidence-based prehospi-
and wilderness medicine experts in many areas. TCCC emphasizes tal guideline for external hemorrhage control: American College
the need to consider the specific tactical scenario in formulating a of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014;
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occur in wilderness areas. The TCCC and the WMS conducted Butler FK. Two decades of saving lives on the battlefield: tactical com-
a workshop in which they developed guidelines for combat ca- bat casualty care turns 20. Mil Med. 2017;182 (3):e1563–e1568.
sualty care in wilderness settings (Butler and Zafren 1998). Fen- doi:10.7205/MILMED-D-16-00214
tanyl lozenges recommended for analgesia in TCCC (Butler 2014 Butler FK Jr. Tactical combat casualty care – beginnings. Wilderness En-
viron Med. 2017;28(2S):S12–S17. doi:10.1016/j.wem.2016.12.004
– Triple Option) were previously recommended for use in wil- Butler FK. Leadership Lessons Learned in Tactical Combat Casualty
derness trauma care in 1999 (Weiss 1999). Hemostatic dressings Care. J Trauma Acute Care Surg. 2017;82(6S Suppl 1):S16-S25.
and tourniquets used in TCCC are the mainstays for controlling doi:10.1097/TA.0000000000001424
life-threatening external hemorrhage in the wilderness (Drew Butler FK, Bennett B, Wedmore CI. Tactical combat casualty care and
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supplement to the WMS-sponsored journal Wilderness and Envi- Analgesia Plan for Tactical Combat Casualty Care: TCCC Guide-
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