Page 40 - Journal of Special Operations Medicine - Summer 2015

system to advance prehospital documentation and Doctrine/Policy
performance improvement.
4. The designation of the JTS as a DoD Center of Ex- CBA Question #1: What is the standard of care for pre-
hospital care in US DoD Combat Operations?
cellence and as the lead agency for Trauma Care
and Trauma Systems. CBA Question #2: Are the TCCC Guidelines the US
5. The realignment of CoTCCC under the JTS to DoD Combat Operation prehospital standard of care?
strengthen its role in providing best-practice pre-
hospital trauma-care recommendations. 1. Observations
6. Implementation of the initiative to train and sustain a. In 2013, a senior-level Unit Surgeon declined to es-
all tactical evacuation medics as critical care flight tablish the TCCC Guidelines as the standard of care
paramedics. for prehospital trauma care within CJOA-A for US
7. The initial implementation of blood-product ad- Forces. The Unit Surgeon reported that he felt that
ministration onboard tactical evacuation platforms standards of care and training standards should be
within CJOA-A and now elsewhere within the determined at the Army Medical Department level.
CENTCOM AOR. Further, having a USFOR-A FRAGO establish a
8. The deployment and distribution of junctional tour- standard of care would have no effect on stateside
niquets to control noncompressible hemorrhage in practices. It was also related that there was signifi-
the prehospital environment. cant concern and hesitation over applying the term
9. The expanded authorization of tranexamic acid “standard of care” to the medic’s scope of practice
(TXA) to include all deployed prehospital forces to since it “implies a level of scrutiny will be applied to
control noncompressible hemorrhage in the prehos- a bunch of 19 year olds with little training.”
pital environment. b. As determined by data analysis from the JTS, the
10. The authorization of ketamine as a prehospi- most common and prevailing prehospital method
tal pain management therapy in accordance with for treating pain in CJOA-A is the absence of
TCCC Guidelines with clear Guideline indications treatment with a pain medication. Unlike hos-
to use low-dose ketamine as the battlefield anal- pitals or medical treatment facilities that have
gesic of choice for casualties in severe pain/shock/ adhered to The Joint Commission’s pain manage-
respiratory distress, or at significant risk of these ment standards since 2001, there is no specified or
conditions. enforced prehospital pain management standard.
11. Creation and manning of the deployed JTTS Pre- This strongly suggests that the absence of a stan-
hospital Division (physician, physician assistant, dard of care contributes directly to an absence of
and senior medic) with a JTTS Prehospital Care care, and, subsequently, undue suffering, morbid-
Director in CJOA-A filled by a hand-selected phy- ity, and mortality.
sician with knowledge and experience in point-of- 2. Discussion
injury (POI) prehospital combat trauma care. Since 2001, the Committee on Tactical Combat Ca-
sualty Care (CoTCCC) has continuously reviewed,
The significant and critical successes over the past 12 updated, and published TCCC Guidelines based on
years attributed to the JTTS and the DoD JTS are a up-to-date, evidence-based best practices for prehos-
direct result of their ability to capture data and infor- pital trauma care on the battlefield. The CoTCCC
mation from POI onward to reduce morbidity and mor- is a hand-selected 40-person organization compris-
tality through performance improvement initiatives and ing trauma surgeons, emergency medicine and criti-
refinement of clinical practice guidelines. The prehos- cal care providers, and prehospital traumatologists
pital elements of this data-capture capability have only with a vast amount of combat experience. The TCCC
been more recently achieved. Guidelines are considered to be the state of the art
by many military and civilian organizations through-
out the world. Nevertheless, though doctrinally ac-
DOTMLPF Analysis
cepted and with TCCC training requirements across
Similar to safety mishap investigations, rarely is a single the Services, there remains no DoD or Service policy
event or circumstance in the mishap chain causative in dictating the standard of care for prehospital combat
and of itself. In contrast, from a systems perspective, any casualty care. In the absence of mandated DoD stan-
one of a number of those factors, if interrupted could dards, combatant commanders and medical leaders at
disrupt the entire mishap chain and prevent a nega- all levels may and do establish their own standards, to
tive outcome. Prehospital battlefield trauma is equally include ignoring all or some of the TCCC Guidelines.
complex and multifactorial. Recognition and correction 3. Finding
of any of the following systemic discrepancies could The lack of standardized TCCC capability may rep-
achieve significant improvements in patient outcomes. resent a causal factor for the increased number of

30 Journal of Special Operations Medicine Volume 15, Edition 2/Summer 2015