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consider new evidence that becomes available in the field of by Tarpey in 2005, but others soon followed, and TCCC gradu-
prehospital trauma care; and propose modifications to TCCC ally gained acceptance throughout the entire U.S. military (Butler
as indicated 2017, Butler 2010, Butler 2007, Holcomb 2005, Tarpey 2005,
Gresham 2005, Butler 2001, DeLorenzo 2001, Pappas 2001, Allen
As the name implies, TCCC is used when casualties are sustained 1999, Malish 1999).
during combat missions. Prehospital trauma care in the military is
most commonly provided by enlisted combat medical personnel— References
medics in the Army and in the Navy SEAL community, corpsmen Allen RC, McAtee JM. Pararescue Medications and Procedures Man-
in the Navy and Marine Corps, and both medics and parares- ual. Air Force Special Operations Command; 1999.
cuemen (PJs) in the Air Force—although physicians and physician Butler FK. Two decades of saving lives on the battlefield: tactical com-
assistants also provide prehospital care to the wounded in some bat casualty care turns 20. Mil Med. 2017;182 (3):e1563–e1568.
settings. doi:10.7205/MILMED-D-16-00214
TCCC is divided into three phases: Care Under Fire/Threat, Tac- Butler FK, Blackbourne LH. Battlefield trauma care then and
tical Field Care, and Tactical Evacuation Care. In the Care Under now: a decade of tactical combat casualty care. J Trauma Acute
Fire phase, combat medical personnel and their units are under Care Surg. 2012;73(6 Suppl 5):S395–S402. doi:10.1097/TA.
0b013e3182754850
effective hostile fire, and the care they can provide to the wounded Butler FK Jr, Holcomb JB, Giebner SD, McSwain NE, Bagian J. Tac-
is very limited. In the Tactical Field Care phase, medical personnel tical combat casualty care 2007: evolving concepts and battlefield
and their casualties are no longer under effective hostile fire, and experience. Mil Med. 2007;172(11 Suppl):1–19. doi:10.7205/mil
more extensive care is feasible. Finally, in the Tactical Evacuation med.172.supplement_1.1
phase of care, casualties are transported to a medical facility by Butler FK Jr. Tactical medicine training for SEAL mission command-
an aircraft, ground vehicle or boat, and there is an opportunity to ers. Mil Med. 2001;166(7):625–631.
provide additional medical personnel and equipment and elevate DeLorenzo RA. Medic for the millennium: The US Army 91W health
the level of care rendered. care specialist. Mil Med. 2001;166(8):685–688.
Gresham JD. Giving Back, Again: Master Sergeant Luis Rodriguez and
References the Tactical Combat Casualty Care Course. The Year in Military
Bellamy RF. How shall we train for combat casualty care? Mil Med. Medicine; 2005.
1987;152(12):617–621. Holcomb, JB. The 2004 Fitts Lecture: current perspective on combat
Butler FK. Two decades of saving lives on the battlefield: tactical com- casualty care. J Trauma. 2005;59(4):990–1002. doi:10.1097/01.
bat casualty care turns 20. Mil Med. 2017;182(3):e1563–e1568. ta.0000188010.65920.26
doi:10.7205/MILMED-D-16-00214 Malish RG. The medical preparation of a special forces company for
Butler FK Jr. Tactical combat casualty care – beginnings. Wilderness En- pilot recovery. Mil Med. 1999;164(12):881–884.
viron Med. 2017;28(2S):S12–S17. doi:10.1016/j.wem.2016.12.004 McSwain NE, Frame S, Paturas Jl, eds. Prehospital Trauma Life Sup-
Butler FK. Military history of increasing survival: The US military ex- port Manual. Fourth Edition; Mosby; 1999.
perience with tourniquets and hemostatic dressings in the Afghan- Pappas CG. The ranger medic. Mil Med. 2001;166(5):394–400.
istan and Iraq conflicts. Bull Am Coll Surg. 2015;100(1 Suppl): Richards TR. Commander, Naval Special Warfare Command letter.
60–64. 1500 Ser 04/0341; 9 April 1997.
Butler FK Jr, Hagmann J, Butler EG. Tactical Combat Casualty Care in Tarpey M. Tactical combat casualty care in Operation Iraqi Freedom.
Special Operations. Mil Med. 1996;161 Suppl:3–16. doi:10.1007/ U.S. Army Medical Department Journal. 2005;April-June:38–41.
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Maughon JS. An inquiry into the nature of wounds resulting in killed The Committee on Tactical Combat Casualty Care
in action in Vietnam. Mil Med. 1970;135(1):8–13. and the TCCC Working Group
The ongoing need for periodic updates to the TCCC guidelines
TCCC: 1996–2001 was recognized in the initial TCCC paper, which recommended
The first TCCC course was taught in 1996 in the Undersea Medi- that the TCCC guidelines be revised as needed by a Department
cal Officer course sponsored by the Navy Bureau of Medicine and of Defense-sponsored committee established for this purpose
Surgery (BUMED). After this action was taken and after a year of (Butler 1996). This concept was endorsed by the U.S. Special Op-
presenting the novel TCCC concepts to both military and civilian erations Command (USSOCOM), and the Committee on Tacti-
medical audiences with strongly positive feedback, TCCC training cal Combat Casualty Care (CoTCCC) was subsequently funded
was mandated for all SEAL corpsmen (Richards 1997). in 2001 as a USSOCOM Biomedical Research Program (Butler
The incorporation of the TCCC guidelines into the Prehospital 2017 – TCCC Turns 20, Butler 2017 – TCCC LLL). The command
Trauma Life Support (PHTLS) textbook was an important mile- that volunteered and was selected to execute this project was the
stone in the evolution of TCCC. The fourth edition of this manual, Naval Operational Medicine Institute. Through the leadership of
published in 1999, contained a chapter on military medicine for Navy Captains Doug Freer and Stephen Giebner, coordination
the first time, and TCCC was included as part of that chapter with Navy Medicine leaders was also conducted to ensure that
( McSwain 1999). The recommendations contained in the PHTLS there would be long-term programmatic support of the newly-
textbook carry the endorsement of the American College of Sur- established CoTCCC. The Navy Bureau of Medicine and Surgery
geons Committee on Trauma and the National Association of (BUMED) programmed for financial and personnel support of
Emergency Medical Technicians. TCCC is the only set of battle- the CoTCCC beginning in fiscal year 2004. In fiscal years 2007
field trauma care guidelines ever to have received the endorsements through 2012, the Office of the Surgeon General of the Army, the
of these two internationally respected trauma care organizations U.S. Army Institute of Surgical Research, and the Defense Health
as well as that of the U.S. Department of Defense (DoD). Board also provided substantial support for the CoTCCC.
During the peace interval that existed for the United States from Since the goal of TCCC is to provide the best possible medical
1996 to 2001, adoption of TCCC by the U.S. military proceeded care consistent with good small-unit tactics, it was and is essen-
slowly. TCCC was implemented in the Navy SEAL community, tial that the membership of the CoTCCC include combat medical
the 75th Ranger Regiment, the U.S. Army Special Missions Unit, personnel as well as physicians. It is also critical to have tri-service
and the Air Force Special Tactics units as well as only a few inno- representation to ensure that differences in doctrine and experi-
vative units in the conventional military. That all changed when ence between the Army, Navy, and Air Force medical departments
the attacks on the U.S. by Al Qaeda resulted in a U.S. military are identified and that the best prehospital trauma care practices
response in Afghanistan, followed in 2003 by the invasion of Iraq. from each are incorporated into TCCC. The combat medics se-
The first published report of TCCC’s success in combat was that lected for the CoTCCC included Navy SEAL corpsmen, Navy

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