Page 43 - Journal of Special Operations Medicine - Summer 2015

are a product of the CoTCCC, a DoD-sponsored en- procurement practices, and policy changes that could
tity under the USAISR, they have doctrinal validity in improve trauma-care delivery and, ultimately, reduce
principle as well as practice. As such, they qualify as morbidity and mortality. The lack of established or
“Authoritative but not Directive,” guidance. JP1 in- defined standards of care and performance makes
dicates that authoritative guidance is closely related quality measurement and quality assurance challeng-
to command authority that rests with the Geographic ing. Data collection, data analysis, and performance
Combatant Commander or higher at the Services, US improvement are difficult to accomplish without a
Special Operations Command, or the DoD. standard for care.
3. Findings 3. Findings
Absent a validated joint requirement, which is cap- There is no evidence that the DoD or CJOA-A has
tured doctrinally, the prevailing resource-constrained policies or procedures in place to validate or enforce
environment will challenge Services to fully organize, prehospital care within an organization. Service-
train, and equip to TCCC standards. specific doctrine requiring Unit Surgeons to each
establish a standard of care, allows for variant, non-
CBA Question #4: What policies or regulations are used standard delivery of battlefield trauma care across
to conduct prehospital quality assurance and quality the Force. Furthermore, even within a single com-
improvement programs in the DoD as demonstrated in mand rotation of Unit Surgeons introduces and mag-
CJOA-A? nifies discontinuity of unit trauma-care standards.

CBA Question #5: Are the TCCC Guidelines currently CBA Question #6: Is delivery of TCCC standardized
enforceable as a prehospital standard of care?
across combatant organizations?
1. Observations CBA Question #7: Does our current doctrine support
a. CENTCOM Regulation 40-1, Clinical Quality the effective implementation of TCCC Guidelines at the
Assurance Programs (17 Oct 2012) does not men- tactical and operational levels on the battlefield?
tion quality assurance or quality improvement in
the prehospital combat environment, limiting its 1. Observations
application to medical and dental treatment facili- a. A current Division Surgeon, and future Regional
ties. Likewise, though not excluding medical care Command (RC) Surgeon, related that his division
in the prehospital battlefield environment, none of medical leadership organized a standing committee
the Services’ quality assurance directive guidance of providers to review the TCCC Guidelines. They
instructions specifically address it either. then decided if implementing the guidelines was
b. There does not seem to be an official policy or reg- appropriate for their organization. The surgeon
ulatory requirement to conduct prehospital qual- further related that they decided to neither field
ity assurance and quality improvement in the DoD nor authorize tranexamic acid (TXA) within their
as demonstrated in CJOA-A. The Medical Les- division due to their assessment of a perceived lack
sons Learned (MLLs) efforts may provide some of efficacy and significant logistical requirements.
high-level or general oversight, but they lack the Their decision to establish their own prehospital
capability to provide feedback on a case-by-case committee actually degraded their TCCC delivery
or provider-by-provider basis. Nor are the MLLs capability in accordance with the guidelines.
captured and aggregated across the CJOA-A. b. The Services use different medical sets, kits, and
c. As of August 2013, the JTTS does provide a pre- outfits across the spectrum of prehospital care
hospital trauma registry service. However, with- delivery. A USMC Improved First Aid Kit (IFAK)
out published standards, the team cannot provide is different than a USA IFAK. Different medical
1
quality assurance in the absence of a benchmark materials are identified and used to treat the same
against which to measure standard of performance. trauma pathophysiology. There are educational
2. Discussion and skill-based differences across the Services.
As of August 2013, USCENTCOM’s JTTS, with the Army Medics, Navy Corpsman, and Air Force
support of a USFOR-A FRAGO, began collecting Medical Technicians, along with Special Opera-
TCCC Cards and TCCC AARs from CJOA-A casual- tions personnel, receive different levels of training,
ties. Compliance with this FRAGO requirement has attend different courses, and are determined quali-
varied from 9% to 23% from August 2013 to De- fied under different standards.
cember 2013. Compliance was calculated using the
USCENTCOM J-1 Casualty Tracker Report. This
1. At the time of this article’s submission, the Services are
report was compared with TCCC AARs received by preparing to field a Joint IFAK with many similar components.
the JTTS. The low compliance rate precludes mean- However, each Service is adding to or deleting items from the
ingful trend analysis, cost-effective research, directed kits master inventory. See page 36 footnote comments.

Saving Lives on the Battlefield (Part II) 33