Page 58 - Journal of Special Operations Medicine - Fall 2015

The Ranger First Responder Program and
Tactical Emergency Casualty Care Implementation

A Whole-Community Approach to
Reducing Mortality From Active Violent Incidents

Andrew D. Fisher, APA-C; David W. Callaway, MD; Josh N. Robertson, MD;
Shane A. Hardwick, EMT-P; Joshua P. Bobko, MD; Russ S. Kotwal, MD, MPH

ABSTRACT
Active violent incidents are dynamic and challenging Reducing mortality from civilian AVIs is a complex chal-
situations that can produce a significant amount of pre- lenge. Success requires a whole-community response
ventable deaths. Lessons learned from the military’s ex- that is rapid, aggressive, and multiagency. Appropri-
perience in Afghanistan and Iraq through the Committee ately analyzed and translated, the military combat ex-
on Tactical Combat Casualty Care and the 75th Ranger perience offers important lessons that can inform the
Regiment’s Ranger First Responder Program have helped development of civilian response paradigms to address
create the Committee for Tactical Emergency Casualty these complexities. The most developed translation has
Care (C-TECC) to address the uniqueness of similar been the evolution of military Tactical Combat Casu-
wounding patterns and to end preventable deaths. We alty Care (TCCC) to civilian Tactical Emergency Casu-
propose a whole-community approach to active violent alty Care (TECC). The sentinel work of the Committee
incidents, using the C-TECC Trauma Chain of Survival on Tactical Combat Casualty Care (CoTCCC) was the
and a tiered approach for training and responsibilities: first to emphasize the critical relationship between the
the first care provider, nonmedical professional first re- tactical environment and appropriate trauma interven-
sponders, medical first responders, and physicians and tion. Many have credited TCCC as a major factor in the
trauma surgeons. The different tiers are critical early reduction of potentially preventable combat mortality
links in the Chain of Survival and this approach will to the lowest levels in recorded history. However, the
2–4
have a significant impact on active violent incidents. consistent application of TCCC and compliance with
5
TCCC principles across all forces in combat is mixed.
Keywords: Committee on Tactical Combat Casualty Care; In the civilian sector, the C-TECC has taken up this
Ranger First Responder Program; Committee on Tactical mantle, to serve as a best-practice development group
Emergency Casualty Care; wounding patterns; preventable for the provision of trauma care in high-threat civilian
deaths; Chain of Survival prehospital settings. Nationwide, TECC has been ac-
cepted and endorsed by professional organizations, mu-
nicipalities, and government agencies. 6–9
Introduction
However, as military reports indicate, the mere presence
One of the most challenging civilian first-responder of trauma guidelines does not affect mortality. The key
operations is the response to an active violent incident factor is effective, tiered implementation of these trauma
(AVI), defined here as ongoing violence directed at ci- care protocols and response paradigms during complex
vilians at the time of first responder dispatch. Civilian operations. This paper offers a unique model for a com-
AVIs include active shooter incidents (ASIs), attacks prehensive, whole-community approach to TECC in-
with improvised explosive devices, incidents of ongoing tegration that combines the battle-tested lessons from
violence on first-responder engagement, and so forth. the last 14 years of combat with a historically successful
The AVI definition acknowledges that immediate ac- civilian program model.
tion plans and response standard operating procedures
begin while the responders are traveling to the scene, More Lessons From Combat:
dictating strategic, operational, and tactical actions to The Ranger First Responder Program
include vehicle placement, avenue of approach, crowd
management, a unified command, and a unified casualty In the United States, AVIs are becoming more frequent,
response to support the optimal treatment and evacua- more complex, and more deadly. The recent Boston
tion of casualties. 1 bombing is a stark reminder that high-threat response

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