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force protection modifications, good medicine through evi- best available evidence with the practical realities of combat
dence-based treatment protocols, and standardized medicine medicine. By adopting this systematic approach to grading
through policy initiatives and mandates. For leaders, docu- evidence, the CoTCCC ensures that all TCCC guidelines are
mentation can improve visibility of casualties, augment de- grounded in scientific rigor while remaining adaptable to the
cision-making, validate and refine casualty response systems, unique challenges of combat environments.
refine personnel, training, equipment, and force protection
initiatives, facilitate directed procurement of products, and ul- References
timately reduce morbidity and mortality. 1. Alexander JT, Cifu AS. Interpreting the ACC/AHA Clinical Prac-
tice Guideline Recommendation Classification System. JAMA.
In contrast, the CoTCCC acknowledges and highlights the no- 2021;326(8):761–762. doi:10.1001/jama.2021.9855
table challenges inherent to conducting formal research studies 2. Eastridge BJ, Mabry RL, Blackbourne LH, Butler FK. We don’t
know what we don’t know: prehospital data in combat casualty
in the prehospital battlefield environment. Unlike controlled care. US Army Med Dep J. 2011:11–4.
clinical settings, this environment often lacks the infrastruc- 3. Halperin JL, Levine GN, Al-Khatib SM, et al. Further Evolution of
ture, time, and resources necessary for randomized controlled the ACC/AHA Clinical Practice Guideline Recommendation Clas-
trials or extensive observational studies. In addition to the sification System: a report of the American College of Cardiology/
often complex, severe, and urgent nature of combat injuries, American Heart Association Task Force on Clinical Practice Guide-
enemy forces and the overall battlefield environment can also lines. J Am Coll Cardiol. 2016;67(13):1572–1574. doi:10.1016/j.
jacc.2015.09.001
make it very difficult to follow highly structured federal reg- 4. Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating Pre-
ulatory processes required for formal research investigations, ventable Death on the Battlefield. Arch Surg. 2011;146(12):1350–
testing, and evaluation. 1358. doi:10.1001/archsurg.2011.213
5. McGarry AB, Mott JC, Kotwal RS. A study of prehospital medical
Additionally, ethical considerations prevent the use of placebo documentation by military medical providers during precombat
training. J Spec Oper Med. 2015;15(1):79–84.
controls or withholding potentially life-saving interventions. 6. Robinson JB, Smith MP, Gross KR, et al. Battlefield documentation
As a result, the body of evidence available for some interven- of tactical combat casualty care in Afghanistan. US Army Med Dep
tions may be limited to garrison military and civilian prehos- J. 2016;(2-16):89–94.
pital research. However, battlefield performance improvement
studies, observational data, case reports, and expert consensus
can also help to inform clinical decisions, recommendations, Committee on Tactical Combat Casualty Care
and best practices. (CoTCCC) in 2025
CAPT Travis Deaton - Chair MSG Christopher Hutchison
Importance of Consensus Mr Harold Montgomery – CDR Joseph Kaleiohi
Vice Chair Mr. Win Kerr
While high-quality randomized evidence is preferred, TCCC is MSG Zachary Andrews COL Ryan Knight
often performed in environments where such data may be lim- LTC Michael April CDR Eric Koch
ited or impractical to obtain. In these situations, level of evi- CAPT Sean Barbabella CAPT Joseph Kotora
dence C-EO, expert opinion and consensus, plays a crucial role COL George Barbee SrA Oliver Kreuzer
in informing recommendations. This is particularly apparent HMCS Joshua Beard MAJ Daniel Lammers
for novel treatments or field techniques and procedures where MSG Hunter Black CAPT Lanny Littlejohn
formal studies have not been conducted or are still in progress. HMSC Antonio Boyd CDR Debra Lowry
The use of expert consensus is considered a best practice, with MAJ Brandon Carius MAJ John Maitha
ongoing research encouraged to support or modify these ini- 1SG Cyril Clayton SCPO Richard Neading
tial recommendations. SGM Curt Conklin LtCol D. Marc Northern
CAPT Virginia Damin Mr. Keith O’Grady
Continuous Review and Updates LtCol Erik DeSoucy LtCol Lorenzo Paladino
Mr. Michael Eldred SGM Michael Remley
The evolution of TCCC should be dictated by injuries and the MAJ Andrew Fisher Mr. Ian Richardson
subsequent requirements for prehospital capabilities that help SGM Matthew Garrison Col Stacy Shackelford
to decrease morbidity and mortality. Guided by effectiveness, Col Brian Gavitt CMSgt Travis Shaw
safety, and operational suitability, the CoTCCC is committed Mr. William Gephart CDR Sean Simmons
to a continuous process of reviewing and updating the TCCC LTC Christopher Gonzales HM1 Jonathan Stringer
Guidelines as new evidence emerges. Recommendations that COL Jennifer Gurney COL Micheal Tarpey
are supported by lower-quality evidence, such as Level C, LtCol Christopher Hewitt CDR Russell Wier
should be re-evaluated each time more robust data becomes HMCM Christopher Huse
available. The CoTCCC remains dedicated to balancing the
PMID: 41474876; DOI: 10.55460/C7MG-3GLO

84 | JSOM Volume 25, Edition 4 / Winter 2025